Westlake Health Campus: Wound Care Failures Caused Harm - MI
That arrangement, federal inspectors concluded, caused actual harm to residents.
The inspection was triggered by a complaint. What investigators found when they arrived was a facility where the line of medical authority over wound treatment had effectively dissolved. Nurse Practitioner A, identified in the inspection record, acknowledged the practice directly: providers were not initiating conversations about wound care orders. Nurses were making the calls. Providers were ratifying them after the fact.
For residents with wounds, that distinction is not procedural. Wounds that go without proper assessment and ordered treatment can deteriorate within days. Skin that breaks down in a nursing home setting, particularly on residents who are immobile or have conditions that impair healing, can progress from a manageable sore to a deep, infected wound that requires hospitalization. The inspection record noted that Nurse Practitioner A said antibiotics or other medications would be ordered if a resident needed them, which suggests at least some residents reached the point of requiring medication before a provider had formally engaged with their wound care.
The deficiency was cited at the level of actual harm, meaning inspectors determined that residents were not merely at risk of injury. Some were injured.
How many residents were affected, and what specifically happened to them, is not fully detailed in the portion of the inspection record available. The report notes that few residents were affected. But the harm designation is not a finding inspectors apply loosely. It requires documented evidence that a failure in care caused a resident's condition to worsen, or caused pain, or caused a complication that would not have occurred under proper care.
The facility's response, once inspectors were on-site, was to move quickly. Staff received education. A new wound nurse was brought in. A new order set was established, built around guidelines tied to each resident's individual risk of skin breakdown. Providers reviewed current residents. The facility demonstrated to inspectors that it was monitoring whether the corrective actions were holding.
Inspectors found that the facility had, by the time of the survey, brought itself back into compliance. The deficiency was cited as past noncompliance, meaning the problems had been identified and corrected before the survey concluded. That designation matters for how the violation is classified and whether civil monetary penalties apply, but it does not erase what happened to the residents who were harmed before anyone outside the facility took notice.
The question the inspection record leaves open is how long the wound care arrangement had been operating this way before a complaint brought inspectors through the door. The record does not say. It does not say when the practice of providers signing off on orders without first discussing them with nursing staff began, or how many wound assessments were conducted under that system, or whether the residents who were harmed have since recovered fully.
What the record does say is that the people responsible for ordering wound treatment acknowledged they were not doing it. Nurse Practitioner A did not describe the arrangement as an oversight or an exception. The language in the inspection record is matter-of-fact: they did not call. They left it to the nurse. They would sign later.
In a nursing home, wound care is one of the more closely watched quality indicators precisely because failures are both common and preventable. Pressure injuries, in particular, are considered a marker of overall care quality. Facilities are expected to identify residents at risk, put prevention measures in place, and when wounds develop, ensure that licensed providers are actively directing treatment, not reviewing paperwork after nurses have already decided what to do.
The new order set Westlake put in place is designed to close that gap, giving nurses structured guidelines based on a resident's skin breakdown risk rather than leaving them to exercise independent clinical judgment that belongs with a provider. Whether that system holds, and whether the providers who acknowledged never calling nursing staff have changed their practice, will be a matter for future inspections to determine.
The residents who were harmed during the period when no one was making that call are not named in the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westlake Health Campus from 2025-10-07 including all violations, facility responses, and corrective action plans.
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 10, 2026 · Our methodology
Westlake Health Campus in Commerce, MI was cited for violations during a health inspection on October 7, 2025.
That arrangement, federal inspectors concluded, caused actual harm to residents.
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.