Inspection Reports for
The Oaks at Belmont
6081 West River Drive, Belmont, MI, 49306
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 1
Date: Jan 8, 2026
Visit Reason
The inspection was conducted to evaluate the facility's implementation of infection prevention and control measures, specifically related to Contact Precautions for a resident diagnosed with conjunctivitis.
Findings
The facility failed to properly implement Contact Precautions for Resident #56, resulting in potential cross contamination of conjunctivitis. Staff were observed not wearing required personal protective equipment and not performing hand hygiene as mandated.
Deficiencies (1)
F 0880: The facility failed to properly implement Contact Precautions for Resident #56 with conjunctivitis, resulting in potential cross contamination. Staff did not wear gowns or gloves and failed to perform hand hygiene when entering and exiting the resident's room.
Report Facts
Residents reviewed for infection control: 6
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nursing Assistant | Observed not wearing PPE and not performing hand hygiene when handling Resident #56's care |
| CNA L | Certified Nursing Assistant | Observed not wearing PPE and not performing hand hygiene when assisting Resident #56 |
| DON B | Director of Nursing | Reported Resident #56 was placed on Contact Precautions and staff should use gowns, gloves, and hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 11, 2025
Visit Reason
The inspection was conducted based on complaints (intakes 2576923 & 1361498) regarding inadequate pressure ulcer care and skin impairment monitoring at the facility.
Complaint Details
This citation pertains to intakes 2576923 and 1361498. The complaint investigation found substantiated failures in skin assessment and treatment leading to harm.
Findings
The facility failed to ensure thorough assessment and monitoring of skin impairments for two residents, resulting in one resident being hospitalized for sepsis due to an unidentified Stage 3 pressure wound and another resident not receiving adequate incontinence care or prescribed skin treatments.
Deficiencies (1)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm to residents.
Report Facts
WBC blood level: 17.4
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/WN D | Registered Nurse/Wound Nurse | Reported unawareness of Resident #101's large sacral pressure wound until hospital notification. |
| CNA E | Certified Nursing Assistant | Reported frequent care of Resident #101 and noted skin condition and incontinence care. |
| Therapy Director P | Therapy Director | Reported Resident #101 required moderate assistance with toileting. |
| LPN G | Licensed Practical Nurse | Recalled Resident #101's buttocks condition. |
| RN L | Registered Nurse | Reported Resident #101's wound and elevated WBC before hospital transfer. |
| RN F | Registered Nurse | Reported care and observations related to Resident #104's wounds and skin condition. |
| ADON C | Assistant Director of Nursing | Reported facility policies on protective equipment and skin observation documentation. |
| NHA A | Nursing Home Administrator | Reported referral from hospital and discovery of undocumented pressure wound. |
| DON B | Director of Nursing | Reported discovery of undocumented pressure wound and initiated facility-wide skin assessments. |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 22, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety standards and infection prevention and control measures.
Findings
The facility failed to prepare and store food according to professional standards, with issues in cooling procedures and cleanliness of kitchen equipment. Additionally, infection control lapses were observed during incontinence care for two residents, including improper hand hygiene and glove use.
Deficiencies (4)
F0812: The facility failed to properly cool food items, with sausages and cheese sauce found at unsafe temperatures and improper cooling methods observed in the kitchen.
F0812: Kitchen equipment and utensils were found with accumulated debris, dust, and dried food residue, indicating inadequate cleaning and sanitation practices.
F0812: The dishwashing machine was not operating within required temperature and pressure specifications, with a missing rinse gauge cover and leaking pressure relief valve.
F0880: The facility failed to maintain infection control during incontinence care for two residents, with staff not performing hand hygiene between glove changes, risking cross-contamination.
Report Facts
Temperature of cheese sauce: 120
Temperature of sausages: 70
Dish machine wash temperature: 145
Dish machine rinse pressure: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in infection control deficiency related to improper glove use and hand hygiene during incontinence care |
| CNA L | Certified Nursing Assistant | Named in infection control deficiency related to improper glove use and hand hygiene during incontinence care |
| FSD T | Food Service Director | Interviewed regarding kitchen food cooling and cleaning practices |
| AFSD U | Assistant Food Service Director | Interviewed regarding food cooling practices |
| RN W | Registered Nurse | Interviewed regarding hand hygiene expectations |
| ADON C | Assistant Director of Nursing/Infection Preventionist | Reported on infection control education and audits |
| DON B | Director of Nursing | Reported on infection control education and audits |
Inspection Report
Renewal
Census: 29
Capacity: 41
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable licensing statutes and rules for The Oaks at Belmont facility.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities. Renewal of the facility's license is recommended.
Report Facts
Number of staff interviewed and/or observed: 12
Number of residents interviewed and/or observed: 29
Capacity: 41
Inspection Report
Routine
Deficiencies: 3
Date: Nov 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, including accommodation of resident needs, wound care, and dialysis services.
Findings
The facility failed to ensure call lights were within reach for some residents, did not accurately describe and measure a pressure ulcer upon admission, and failed to complete required post dialysis assessments for a resident, resulting in potential risks to resident well-being.
Deficiencies (3)
F 0558: The facility failed to ensure call lights were left within reach for 2 residents, resulting in potential unmet care needs and risk to their physical and psychosocial well-being.
F 0658: The facility failed to accurately describe and measure a pressure ulcer upon admission for 1 resident, resulting in incomplete wound information and potential for wound worsening.
F 0698: The facility failed to ensure post dialysis assessment and monitoring were completed for 1 resident, resulting in potential unpreparedness for decline in resident condition.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN N | Licensed Practical Nurse | Named in pressure ulcer and dialysis post-assessment findings |
| RN AA | Registered Nurse | Named in pressure ulcer and dialysis post-assessment findings |
| DON B | Director of Nursing | Named in pressure ulcer and dialysis post-assessment findings |
| ADON K | Assistant Director of Nursing | Named in dialysis post-assessment findings |
| CNA S | Certified Nursing Assistant | Named in call light accessibility finding |
| LPN F | Licensed Practical Nurse | Named in call light accessibility finding |
| CNA J | Certified Nursing Assistant | Named in call light accessibility finding |
| RN L | Registered Nurse | Named in dialysis post-assessment finding |
Inspection Report
Deficiencies: 1
Date: Nov 15, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in wound care, specifically regarding pressure ulcer documentation upon admission.
Findings
The facility failed to accurately describe and measure a pressure ulcer upon admission for Resident #503, resulting in incomplete wound information being communicated to the healthcare team and potential risk of wound worsening or unmonitored improvement.
Deficiencies (1)
F 0658: The facility failed to accurately describe and measure a pressure ulcer on Resident #503's coccyx upon admission, lacking documentation of wound description and dimensions as required by facility policy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) N | Identified pressure ulcer but failed to document wound description and dimensions. | |
| Wound Registered Nurse (RN) AA | Reported LPN N should have described and measured the pressure ulcer upon admission. | |
| Director of Nursing (DON) B | Reported admission LPN N should have measured and described the pressure ulcer. |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
The document serves as a renewal notification for the Home for the Aged license of The Oaks at Belmont, confirming substantial compliance with public health code and administrative rules over the past year.
Findings
The administrative review revealed substantial compliance with applicable regulations, resulting in the renewal of the facility's license for 12 months effective August 8, 2023.
Report Facts
License duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Wohlfert | Licensing Staff | Signed the renewal notification letter |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: May 31, 2023
Visit Reason
The survey was conducted to assess compliance with nursing home regulations, focusing on resident safety during transfers and infection prevention and control practices.
Findings
The facility failed to ensure safe transfers for one resident, resulting in a fall and potential harm due to staff not following care plan transfer requirements. The facility also failed to ensure proper use of PPE in a resident room with droplet precautions, increasing risk of infection.
Deficiencies (2)
F 0689: The facility failed to ensure safe transfers and implement resident care plan interventions for one resident, resulting in a fall and unsafe transfer due to staff transferring the resident without required assistance.
F 0880: The facility failed to ensure proper use of Personal Protective Equipment in a resident room with droplet precautions, resulting in potential increased cross contamination and higher infection risk.
Report Facts
Residents reviewed for accidents and falls: 4
Written counseling incidents: 2
Weekly audits: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Assistant | Counseled for transferring Resident #3 without required assistance |
| CNA E | Certified Nurse Assistant | Counseled for transferring Resident #3 alone without assistance |
| DON B | Director of Nursing | Provided written counseling to CNAs and reported on transfer requirements |
| ADON C | Assistant Director of Nursing | Reported on unsafe transfer incident involving Resident #3 |
| LPN F | Licensed Practical Nurse | Reported on transfer incident and educated CNA E about care plans |
Inspection Report
Original Licensing
Capacity: 41
Deficiencies: 0
Date: Feb 9, 2021
Visit Reason
The inspection was conducted as part of the original licensing study for The Oaks at Belmont to determine compliance with applicable licensing statutes and administrative rules.
Findings
The facility was found to be in substantial compliance with home for the aged public health code and administrative rules. The report describes the physical layout, security features, and program services offered, and notes occupancy and fire safety approvals.
Report Facts
Capacity: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Corbin | Authorized Representative | Named as authorized representative of the facility |
| Jana Broughton | Administrator | Named as administrator of the facility |
| Lauren Wohlfert | Licensing Staff | Author of the licensing study report |
| Russell B. Misiak | Area Manager | Approved the licensing study report |
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