Westwood Nursing Center: Elopement Cover-Up Failures - MI
Resident 304 came to Westwood Nursing Center carrying diagnoses of Schizoaffective Disorder, Bipolar Type, Delusional Disorder, and Post-Traumatic Stress Disorder. On admission, staff completed an elopement risk assessment and scored him a five — high enough to flag him as someone who needed a plan, needed interventions, needed watching. He was cognitively intact, a BIMS score of 13 confirmed that, which meant he was capable of thinking through how to get out.
Nobody wrote a care plan. Nobody put interventions in place.
At approximately midnight on April 6, 2026, Resident 304 exited the facility through a second-story window and landed on the ground below. He was taken by emergency services for medical treatment and hospitalized.
What followed was an investigation that inspectors, reviewing the facility's own records two months later, found answered almost none of the questions that mattered.
The facility's incident report documented that the event happened and that staff called emergency services. That was largely where the documentation stopped being useful. Inspectors found no record of any inquiry into how Resident 304 was able to reach and open a second-story window without anyone noticing, no assessment of whether the window had functioning safety mechanisms, and no evaluation of the environmental conditions that made the exit possible. Staff interviews were incomplete. There was no examination of whether the facility's own elopement prevention procedures had been followed — or ignored — in the weeks between his admission and the night he went out the window.
When inspectors interviewed the Assistant Director of Nursing on May 26, she said an investigation had been completed. She could not produce evidence that it had ever asked the most basic question: why, after the facility's own assessment identified this resident as an elopement risk on the day he was admitted, did no one ever write a care plan or put a single intervention in place?
The Administrator told inspectors he came to the facility after being notified of the incident and began the reporting process. He acknowledged, according to inspection records, that the investigation's focus was primarily on documenting what happened and satisfying reporting requirements.
What it did not do was conduct a root cause analysis. There were no corrective actions identified in the record addressing the missing care plan, the absent interventions, the question of how staff monitoring failed, or any accountability measure connected to the window. The facility did not identify what system failures led to the incident. It did not identify what would prevent the same thing from happening again.
Westwood Nursing Center is disputing the citation.
That dispute is worth holding alongside what the record shows. A man arrived at the facility with a psychiatric history that included documented risk of elopement. The facility's own intake process caught that risk and scored it. Then the facility did not act on its own finding for however long he lived there before April 6. When he was seriously hurt, the investigation that followed did not examine why.
The inspection, a complaint-based review completed May 26, 2026, covered three residents for elopement-related concerns. Deficiencies were cited for one.
Resident 304 was hospitalized. The inspection report does not say what his injuries were, whether he recovered, or where he is now.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westwood Nursing Center from 2026-05-26 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: August 13, 2026 · Our methodology
Westwood Nursing Center in Detroit, MI was cited for violations during a health inspection on May 26, 2026.
He was cognitively intact, a BIMS score of 13 confirmed that, which meant he was capable of thinking through how to get out.
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.