Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Villa At Great Lakes Crossing during CMS and state inspections, most recent first.
The facility failed to ensure timely review and submission of PASARR forms for three residents, potentially impacting their mental health care. One resident with schizophrenia lacked a Level II evaluation, another with dementia and mood disorders had incomplete records, and a third resident's evaluation request was rejected due to early submission. The facility's policy on PASARR guidelines was not adhered to, leading to these deficiencies.
A facility failed to develop and implement a care plan for a resident with an indwelling catheter, leading to potential unmet care needs. An LPN was unaware of the catheter's presence, and the care plan only addressed nephrectomy tubes. The resident, with multiple diagnoses and requiring assistance with ADLs, had no care plan for the catheter, as acknowledged by both the LPN and DON.
A resident's oxygen tank was found improperly stored at their bedside, creating a potential hazard. The tank was full and propped between the bed and table without a stand, contrary to facility policy. The resident, who has COPD and other health issues, sometimes adjusts their oxygen flow independently. The facility's policy requires secure storage of medical gas cylinders, which was not followed in this instance.
A resident with an indwelling foley catheter was found without a leg strap, contrary to the facility's urinary catheter policy. Staff interviews confirmed the absence of the strap and acknowledged the risk of catheter pulling, which could cause pain. The resident had intact cognition and was admitted with multiple diagnoses, including pneumonia and congestive heart failure. The facility's policy requires daily checks of catheter straps during AM and PM care.
The facility failed to date respiratory equipment for two residents, compromising safe respiratory care. A resident with intact cognition and another with impaired cognition were both observed with undated nebulizer masks and tubing. An LPN stated that a contracted company changes and dates the equipment weekly, but acknowledged the oversight. The DON confirmed that staff should check daily for accurate dating, as per facility policy.
A resident sustained a fractured tibia and fibula after being transported in a manual wheelchair instead of their usual power wheelchair, which was deemed unsuitable for the transport van. The resident's foot slipped off the pedal during transport, resulting in the injury. The facility's policy required proper assessment for wheelchair use, which was not adequately followed, leading to the incident.
A resident with severe cognitive impairment and multiple medical conditions, including cerebral palsy and osteoporosis, suffered a toe fracture. The facility failed to conduct a thorough investigation into the injury, as the incident report lacked staff interviews and detailed accounts of the event. The DON suggested the fracture occurred spontaneously, but there was no evidence to confirm the timing of the injury. This lack of investigation led to a deficiency citation.
A resident with severe cognitive impairment and a recent toe fracture did not receive timely pain management. Despite showing signs of pain, the first pain medication order was made a day after the fracture was identified. The facility's policy for assessing pain in cognitively impaired residents was not followed, as confirmed by the DON.
A resident with impaired cognitive function experienced a fall, and an x-ray revealed an acute distal tibial fracture. The facility failed to notify the physician of the abnormal results in a timely manner, delaying further treatment. Staff interviews indicated that the physician was texted but not called, and no follow-up attempts were documented. The facility's policy requires immediate notification of changes in a resident's condition to the attending physician.
A resident with dysphagia and nutritional deficiency did not receive tube feeding as per physician orders, leading to potential unmet nutritional needs. Observations showed the feeding pump was not running, and staff interviews revealed the feeding was not documented as given. The DON confirmed the resident should have received 1350cc but only received 815cc. The midnight nurse removed the feeding due to the resident pulling on it, but this was not documented.
Failure to Ensure Timely PASARR Screening and Documentation
Penalty
Summary
The facility failed to ensure timely review, revision, and submission of Preadmission Screening (PAS) and Annual Resident Review (ARR) forms for mental illness and intellectual disabilities to the local state agency for three residents. This resulted in the potential for these residents not to receive appropriate care and services for their mental health needs. The deficiency was identified during a review of the electronic medical records and interviews with facility staff. For one resident, identified as R13, the facility did not document a Level II evaluation or evidence that such an evaluation was requested for 2024, despite the resident having a diagnosis of paranoid schizophrenia and being prescribed antipsychotic medication. The Corporate Social Worker acknowledged that a determination letter should have been sent by the state agency due to a dementia diagnosis, which was not documented on the necessary forms. Additionally, the facility's records did not include a completed 3878 form for this resident. Another resident, R15, had a diagnosis of unspecified dementia, psychotic disorder, and mood disorder. The facility's records did not include an annual 3877 or 3878 form, and the Corporate Social Worker was unaware that these forms are part of the resident's medical record. For a third resident, R56, the facility failed to complete an annual Level II evaluation by the required date, and the request for evaluation was submitted too early and subsequently rejected. The facility's policy on PASARR guidelines was not followed, leading to these deficiencies.
Failure to Address Indwelling Catheter in Resident's Care Plan
Penalty
Summary
The facility failed to develop, implement, and revise care plans for a resident with an indwelling catheter, resulting in the potential for unmet care needs. During an observation, an LPN was unaware of the presence of the indwelling catheter, mistakenly believing the resident only had nephrectomy tubes. However, the observation confirmed the presence of the indwelling catheter, which was not addressed in the resident's care plan. The resident, who was admitted with multiple diagnoses including encephalopathy, epilepsy, acute kidney failure, dissection of the abdominal aorta, and protein-calorie malnutrition, was cognitively intact and required assistance with activities of daily living. Despite these needs, the care plan lacked any mention of the indwelling catheter, a fact acknowledged by both the LPN and the DON. The facility's policy requires comprehensive, person-centered care plans, but this was not adhered to in this case.
Unsafe Storage of Oxygen Tank at Resident's Bedside
Penalty
Summary
The facility failed to ensure the safe storage of an oxygen tank at the bedside of Resident 54, who was one of three residents reviewed for respiratory care. During an observation, it was noted that the oxygen cylinder was propped between the resident's bed and bedside table without a stand, creating a potential environmental hazard. The oxygen cylinder was full, as indicated by the gauge, and if it were to fall, it could become a dangerous projectile due to the high-pressure release of oxygen. Resident 54, who was observed sitting in a wheelchair with nasal cannula oxygen tubing, mentioned needing the oxygen to breathe and sometimes adjusting the oxygen flow themselves when experiencing shortness of breath. The resident's medical record indicated a diagnosis of Chronic Obstructive Pulmonary Disease, Anxiety, Difficulty Walking, and Muscle Weakness, with a cognitive assessment showing intact cognition. The facility's policy on medical gas cylinder storage requires that all cylinders be physically supported to prevent mechanical hazards. However, the staff failed to adhere to this policy, as evidenced by the inappropriate storage of the oxygen cylinder. The Nursing Home Administrator acknowledged that staff were responsible for ensuring the safe storage of oxygen equipment, but this was not followed in the case of Resident 54.
Deficiency in Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling foley catheter, leading to a deficiency in catheter care. On January 13, 2025, the resident was observed without a leg strap to secure their catheter, which could potentially cause irritation or trauma. The resident, who was admitted with diagnoses including pneumonia, congestive heart failure, dysphagia, muscle weakness, and bipolar disorder, had intact cognition as per their BIMS score. Interviews with staff, including a CNA, a wound care nurse, and an LPN, confirmed the absence of a leg strap and acknowledged the risk of catheter pulling, which could cause significant pain. The Director of Nursing stated that catheter straps should be checked daily during AM and PM care. The facility's urinary catheter policy from March 2014 requires the use of a leg strap secured to the inner thigh to prevent catheter movement and friction at the insertion site.
Failure to Date Respiratory Equipment for Residents
Penalty
Summary
The facility failed to date respiratory equipment for two residents, leading to a deficiency in providing safe and appropriate respiratory care. Resident 16 was observed with a nebulizer mask and connecting tubing that were not dated. This resident had a pertinent diagnosis of Pneumonia, Congestive Heart Failure, Dysphagia, Muscle Weakness, and Bipolar, with intact cognition as indicated by a BIMS score of 15/15. Licensed Practical Nurse (LPN) A mentioned that a contracted respiratory company is responsible for changing and dating the tubing every Friday. Similarly, Resident 9 was observed with undated nebulizer equipment. This resident had a diagnosis of Sepsis, Respiratory Failure, Dysphagia, Failure to Thrive, Muscle Weakness, and Depression, with impaired cognition as indicated by a BIMS score of 0/15. LPN A acknowledged that the nebulizer mask should have been dated. The Director of Nursing (DON) confirmed that the facility has a policy requiring staff to check daily to ensure all tubing is accurately dated, and that a company comes weekly to change and label respiratory tubing. The facility's policy from July 2015 mandates that respiratory supplies be routinely changed or cleaned to prevent infections, with nebulizers to be changed weekly or as needed, and all supplies dated upon opening.
Inappropriate Wheelchair Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the use of an appropriate wheelchair for a resident, resulting in a fractured tibia and fibula. The incident occurred when two CNAs transferred the resident into a manual wheelchair for a medical appointment, despite the resident's usual use of a power wheelchair. The power wheelchair was deemed unsuitable for transport in the van, leading to the decision to use a manual wheelchair instead. During the transport, the resident's foot slipped off the wheelchair pedal multiple times, eventually getting caught under the chair, which resulted in the fractures. The resident had previously been evaluated and found unable to propel a manual wheelchair due to decreased active range of motion and strength in the lower extremities. The facility's policy required residents to be assessed for the appropriate type and size of wheelchair, but it appears this was not adequately followed in this case. Interviews with staff revealed that the decision to use a manual wheelchair was made because the power chair would not fit in the transport van, and a geri-chair could not be safely secured. Despite the resident's complaints of pain during the transport, they were sent to their appointment, and it was only upon their return that the injury was fully recognized. The facility's failure to provide an appropriate means of transport directly contributed to the resident's injury.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, leading to a deficiency citation. An anonymous complaint alleged that the facility improperly transferred a resident, resulting in a broken toe. The resident, who had severe cognitive impairment and multiple medical conditions including cerebral palsy and osteoporosis, was observed in a wheelchair with a protruding tongue and did not respond verbally. A progress note indicated that the resident experienced pain in the left foot, leading to an x-ray that revealed a fracture. However, the facility's incident report lacked a thorough investigation, as it did not include interviews with staff or a detailed account of the events leading to the injury. The Director of Nursing (DON) reviewed surveillance footage and suggested the fracture occurred spontaneously when an activity aide placed the resident's feet on the wheelchair pedals. However, there was no evidence to confirm whether the fracture occurred before or after the resident was taken to the activity room. The facility's policy on abuse and injuries of unknown source mandates prompt and thorough investigations, which was not adhered to in this case. The lack of a comprehensive investigation into the incident and the absence of staff interviews contributed to the deficiency finding.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to appropriately assess and manage pain for a resident with severe cognitive impairment, identified as R903. On December 11, 2024, R903 was observed in a wheelchair with their tongue protruding and unable to engage in verbal communication. The resident had a history of cerebral palsy, nutritional deficiency, protein calorie malnutrition, aphasia, and heart failure, with a recent Minimum Data Set assessment indicating severely impaired cognition. On November 22, 2024, a nurse's note documented that an activity aide reported the resident experiencing pain in their left foot, with facial grimaces and moaning upon assessment. An x-ray was ordered, revealing an acute second metatarsal neck fracture. Despite the discovery of the fracture and the resident's demonstrated pain, the facility's records showed that the first order for pain medication was not made until November 23, 2024, a day after the fracture was identified. No pain medication was administered on the day the fracture was discovered. The Director of Nursing confirmed that a numerical pain scale was not appropriate for R903 due to their cognitive impairment, yet no evidence was provided to show that pain medication was administered following the discovery of the fracture. The facility's pain management policy indicated that residents with cognitive impairments should be evaluated using objective observations, such as the PAINAD scale, but this was not adhered to in R903's case.
Failure to Timely Notify Physician of Abnormal X-ray Results
Penalty
Summary
The facility failed to inform the physician of an abnormal x-ray result in a timely manner for a resident who experienced a fall. The resident, who had moderately impaired cognitive function and required substantial assistance with activities of daily living, fell on 7/25/24. An x-ray was ordered and completed the same day, revealing an acute distal tibial fracture. However, the results were not communicated to the physician until 7/30/24, resulting in a delay in further treatment. Interviews with staff revealed that the physician was initially texted about the x-ray results but not called, and there was no documentation of follow-up attempts to contact the physician. The Director of Nursing acknowledged that the nursing staff should have made more attempts to contact the physician and documented any communication. The facility's policy requires immediate notification of changes in a resident's condition to the attending physician, which was not adhered to in this case.
Failure to Administer Tube Feeding Per Physician Order
Penalty
Summary
The facility failed to administer tube feeding per physician order for a resident, resulting in the potential for nutrition needs not being met and unintended weight loss. During an observation, it was noted that the resident's tube feeding was not running, and the pump did not have formula or water hanging. The resident had been admitted with diagnoses including dysphagia and nutritional deficiency and required a feeding tube as per their Minimum Data Set (MDS) assessment. Physician orders specified that the resident should receive enteral feeding with Jevity 1.5 at 75cc/hr for 18 hours, totaling 1350cc, along with an auto flush of 25cc/hr for 18 hours. Interviews with staff revealed that the tube feeding was not documented as given on a specific date, and the resident did not receive the full prescribed amount before the feeding was stopped. The Licensed Practical Nurse (LPN) and Unit Manager both stated they did not remove the resident from the tube feeding. The Director of Nursing (DON) confirmed the discrepancy in the amount fed and acknowledged that the resident should have received the full 1350cc. The DON later reported that the midnight nurse had removed the resident from the tube feeding because the resident was pulling on it, but this removal was not documented in a progress note.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 893 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Heights-detroit | 0 mi | — | 0 | 0 |
| West Oaks Senior Care & Rehab Center | 1.3 mi | — | 1 | 0 |
| Beaconshire Nursing Centre | 1.7 mi | — | 4 | 0 |
| Hartford Nursing & Rehabilitation Center | 1.9 mi | — | 23 | 0 |
| Oakland Nursing Center | 2.3 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Villa At Great Lakes Crossing.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.