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Complaint Investigation

Westwood Nursing Center

May 26, 2026 · Detroit, MI · 16588 Schaefer
Citations 2
CMS Rating 3/5
Beds 108
Provider ID 235444
Healthcare Facility
Westwood Nursing Center
Detroit, MI  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Westwood Nursing Center in Detroit, MI — inspection on May 26, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0610
Freedom from Abuse, Neglect, and Exploitation Deficiencies

score was 13, indicating the resident was cognitively intact.Further review revealed that an Elopement Risk Assessment completed upon admission on [DATE] identified R304 as being at risk for elopement, with a score of five.

Despite the identified risk, the facility failed to develop a care plan or implement interventions to address the resident's elopement risk.A review of the facility's incident report revealed on 4/6/26 at approximately 12:00 a.m., R304 exited the facility through a second-story window and landed on the ground.

The resident sustained injuries requiring emergency medical treatment and hospitalization.

The report also revealed that staff reported to emergency services.The investigation did not document findings in regard to the resident's ability to exit through the second-story window without supervision and the window safety mechanisms and functionality.The investigation did not include documentation of interviews with all staff involved, an evaluation of environmental factors, or a determination of whether facility policies and procedures regarding elopement prevention were followed.

During an interview on 5/26/26, the Assistant Director of Nursing (ADON) stated that an incident investigation was completed following the event.

However, the ADON was unable to provide evidence that the investigation included an assessment of why interventions were not implemented despite the resident being identified as at risk for elopement upon admission.

During an interview on 5/26/26, the Administrator stated that upon notification of the incident, he came to the facility and initiated the reporting process.

The Administrator acknowledged that the focus of the investigation was primarily on documenting the occurrence and reporting requirements.

Record review failed to identify evidence that the facility conducted a comprehensive root cause analysis to determine system failures that contributed to the incident or to identify measures necessary to prevent a similar occurrence in the future.Further review of the facility's investigation failed to identify corrective actions addressing the lack of a care plan, absence of elopement interventions, staff monitoring practices, environmental safety concerns, or accountability measures related to the resident's ability to exit through a second-story window.There was no additional information provided by the exit of survey Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

235444 05/26/2026

Westwood Nursing Center 16588 Schaefer Detroit, MI 48235

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Detroit, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Westwood Nursing Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.