Corewell Health Rehab: Consent Violation for Sedative - MI
The resident, identified in inspection records only as Resident #101, was a woman admitted to the Stevensville facility with severe late-onset Alzheimer's dementia, depression, insomnia, and a history of falls. Starting May 9, 2025, she was given Lorazepam, a benzodiazepine sedative, every night for insomnia. On May 29, she received a one-time dose. By June 4, she had been prescribed Lorazepam three times daily as needed for anxiety. Nobody had asked her family.
On June 8, she fell. At the hospital, her family member and legal decision-maker, identified in the report as FM OO, learned for the first time that the resident had been on Lorazepam. FM OO told inspectors she had not given permission for the medication. She said she felt strongly the resident should not have been put on it at all, because the resident was so mobile.
The consent form in the resident's file, dated April 17, 2025, had no signature. It showed FM OO listed as a participant only as of September 25, 2025, the day inspectors were on site conducting their review. There was no documentation of verbal consent, no notes indicating anyone from the facility had ever called FM OO to discuss the medication, and no record of a conversation about the risks or alternatives.
The facility's care plan for the resident contained nothing about psychotropic medications or monitoring for adverse effects.
Lorazepam is among the medications that carry elevated concern in elderly patients, particularly those with dementia. Falls are a known risk. The resident had already been identified as a fall risk on admission.
When inspectors interviewed the facility's social worker on September 25, she described a process that plainly hadn't been followed. Consents, she said, were supposed to be signed electronically by the resident or decision-maker at admission or when medications changed. If the decision-maker couldn't come in, the form could be sent out for signature, and social work was responsible for following up to get it back. A verbal consent could be obtained over the phone with two staff members present as witnesses.
None of that happened for FM OO.
The social worker told inspectors she could not locate any notes for this resident documenting a consent conversation. She also acknowledged there was no standardized corporate process in place for handling these consents.
A nurse liaison confirmed the same thing that afternoon. There was no documentation anywhere in the record that verbal consent for Lorazepam had ever been received.
The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. Inspectors reviewed seven residents' records for psychotropic medication consent. Only Resident #101's record showed the failure.
That framing, minimal harm, sits uneasily alongside the timeline. A woman with severe dementia and a documented fall risk was given a sedative every night for at least a month before her legal decision-maker knew it was happening. The decision-maker, who had the legal authority to weigh those risks and say no, never got the chance. When she finally learned about the medication, it was because her family member had already fallen.
FM OO told inspectors she would not have consented. Whether that would have changed anything, nobody can say now.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Corewell Health Rehabilitation & Nursing Center - from 2025-10-01 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Corewell Health Rehabilitation & Nursing Center - in Stevensville, MI was cited for violations during a health inspection on October 1, 2025.
Starting May 9, 2025, she was given Lorazepam, a benzodiazepine sedative, every night for insomnia.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.