The Manor of Farmington Hills: Fatal Choking Violation - MI
That finding sits at the center of a federal complaint inspection completed October 30, 2025, at the Farmington Hills facility. Inspectors cited the home for causing actual harm to residents, the second-most serious harm level federal inspectors assign, stopping just short of the "immediate jeopardy" designation that triggers emergency enforcement.
The Director of Nursing, asked by inspectors to explain what the facility's own internal accident investigation had written about the death, said the summary describing R701's death as resulting from "an episode of dysphasia while consuming her meal" was perhaps not "a well written summary." Dysphasia is a disorder affecting the ability to swallow. The DON did not dispute the characterization of how R701 died. She disputed the wording.
Then inspectors asked whether she knew about the hospice team's interdisciplinary group document, the IDG form, which had recorded that R701 was showing signs of trying to eat non-food items and was confused. The DON said she was not aware of that document.
The administrator offered an explanation. The IDG forms, she told inspectors, had been entered into the resident's electronic record by non-medical staff. As such, they "may not have been read."
That sentence, pulled directly from the inspection report, is the core of what federal investigators found: a dying woman's hospice team had flagged dangerous eating behavior in writing, put it in her chart, and the nursing leadership responsible for her care at mealtime had never looked at it.
The hospice interdisciplinary group document exists precisely because patients near the end of life require coordinated care across providers. When a hospice team observes that a resident is confused and reaching for non-food items, that observation is not a clerical note. It is a clinical warning. The Manor's administrator characterized it as something that might go unread because of who clicked the upload button.
Inspectors reviewed the facility's own Incidents and Accidents policy during the investigation. That policy states that potential witnesses to any incident must be interviewed and that those interviews must be documented on the facility's Incident and Accident Investigation Form. It also states that a licensed nurse must complete any incident report. The inspection record does not indicate that witness interviews were conducted in connection with R701's death in the manner the policy requires.
The inspection report does not name the nurses or aides who were present in the dining room when R701 choked. It does not say how many staff were in the room, how long it took anyone to respond, or what response occurred. What it records is that the Director of Nursing, when asked about supervision in the dining room, was asked whether safety checks had been done before nurses entered the room for the meal. The question itself implies that the answer was no, or that the DON could not confirm that it was yes.
Inspectors also reviewed a study from the National Library of Medicine titled "Age Related Changes to Eating and Swallowing Impact Frailty: Aspiration, Choking Risk." The study, cited in the inspection findings, identifies cognitive impairment accompanying dementia as a direct choking risk factor, with specific behaviors including eating too fast, not chewing thoroughly, overfilling the mouth, and swallowing large mouthfuls. It identifies sedating medications as an additional risk factor that supervision at mealtimes can mitigate. It states directly that "inadequate mealtime supervision of individuals at risk of choking has had fatal consequences."
Inspectors did not include that study as background. They included it as evidence. The implication is that R701's risk profile, a hospice patient with documented confusion and aberrant eating behavior, placed her squarely within the population the research identifies as requiring close mealtime supervision. The facility's own records do not show that supervision was in place.
What the inspection report does not contain is also significant. There is no corrective action plan described. There is no statement from the facility disputing the findings. There is no account of what happened in the dining room from any witness, because the inspection record does not indicate that witnesses were interviewed as the facility's own policy required. The DON acknowledged the summary of the death was poorly written. The administrator acknowledged the clinical document may not have been read. Neither statement amounts to a contest of the underlying facts.
The Manor of Farmington Hills is a licensed skilled nursing facility. Residents on hospice receive care from both the facility's nursing staff and an outside hospice team. The hospice team's IDG document is a standard instrument for tracking a patient's condition, goals, and risks across that team. When a hospice patient is placed in a facility dining room for a meal, the facility's staff are responsible for her safety during that meal. The question of whether anyone had read the document warning about her eating behavior is not a paperwork question. It is the question of whether the people responsible for keeping her safe knew what they needed to know to do it.
The Director of Nursing did not know. The administrator's explanation was that non-medical staff had filed the document.
R701 died.
The inspection was filed as a complaint investigation, meaning someone, a family member, a staff member, a hospice worker, contacted regulators after the death. The inspection report does not identify who filed the complaint or what it alleged. It records what inspectors found when they arrived: a dead resident, an accident investigation the DON described as poorly written, and a clinical warning that had been sitting in the electronic record, unread, while the woman it described sat down to eat her last meal.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Manor of Farmington Hills from 2025-10-30 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 5, 2026 · Our methodology
The Manor of Farmington Hills in Farmington Hills, MI was cited for violations during a health inspection on October 30, 2025.
That finding sits at the center of a federal complaint inspection completed October 30, 2025, at the Farmington Hills facility.
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.