Corewell Health Rehabilitation & Nursing Center -
Corewell Health Rehabilitation & Nursing Center - in Stevensville, MI — inspection on October 1, 2025.
Found 5 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
Review of Order dated 5/9/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.5 mg Oral, nightly, Associated Diagnosis: Other insomnia.
Review of Order dated 5/29/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.5 mg Oral, Once, 1200.Associated Diagnosis: Other insomnia.Anxiety Disorder.Review of Order dated 6/4/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.25 mg Oral, 3 times daily, PRN (As needed).Associated Diagnosis: Anxiety Disorder.In an interview on 9/24/25 at 3:27 PM, Family Member/Durable Power of Attorney (DPOA) (FM) OO reported when Resident #101 was admitted to the hospital following a fall on 6/8/25, she was informed Resident #101 was being given Lorazepam at night which she was not aware Resident #101 had been receiving that medication. FM OO reported she did not give her permission for Resident #101 to take Lorazepam and because Resident #101 was so mobile she felt that Resident #101 should not have been put on that medication.Review of Psychotropic Medication Risk/Benefit Consent dated 4/17/25 revealed, no consent for the Lorazepam orders were completed and there was no signature.
The document only indicated FM OO was a participant as of 9/25/25. No documentation submitted to indicate consent was provided verbally. In an interview on 9/25/25 at 09:07 AM, Social Worker (SW) H reported consents for medications would be signed electronically by the decision maker or resident when admitted or when there was a change in medications where consents were needed. SW H reported she would be able to call the decision maker to obtain verbal permission from them with two person's present as witnesses. SW H reported also if the decision maker was not able to come to the building and electronically sign the document, the consent could be sent out to them for signature and social work would have to follow up for return. SW H reported there was not a standard of work process in place from corporate on consents. SW H was unable to locate notes for Resident #101 as well as notes which had indicated a conversation had been had with the decision maker for the prescribed lorazepam medications.During an observation and interview on 09/25/25 at 2:32 PM, Nurse Liaison C reported that there was no documentation in Resident #101's record that there was a verbal consent received for Lorazepam.
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
235164 10/01/2025
Corewell Health Rehabilitation & Nursing Center - 4368 Cleveland Ave Stevensville, MI 49127
Review of Your Rights and Protections as a Nursing Home Resident, revealed, .As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose.
You have the right to decide when you go to bed, rise in the morning, and eat your meals.
Be Free from Abuse and Neglect: You have the right to be free from verbal, sexual, physical, and mental abuse.If you feel you have been mistreated (abused) or the nursing home isn't meeting your needs (neglect), report this to the nursing home, your family, your local Long-Term Care Ombudsman, or State Survey Agency.
The nursing home must investigate and report all suspected violations and any injuries of unknown origin within 5 working days of the incident to the proper authorities.
235164 10/01/2025
Corewell Health Rehabilitation & Nursing Center - 4368 Cleveland Ave Stevensville, MI 49127
Review of policy, Medication Management - safety Continuing Care (Rehab and Nursing Centers) dated [DATE], revealed, .The purpose is to ensure each resident's drug regimen is managed and monitored to promote or maintain the resident's highest
the process for safe administration and storage of medications. administration of the medication based on resident response.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Chart Review: [DATE] All residents' charts were reviewed to identify all residents on psychotropic medication to ensure adequate monitoring. A total of 61 residents were identified as taking anti-anxiety medication/ antipsychotics/antidepressants or any mood stabilizers.
Worklist task/Order Implementation: [DATE] Worklist tasks have been created for all 61 residents to monitor for adverse reactions to psychotropics.
Each task specifies the medication class and symptoms to monitor.
Consent forms: [DATE] All residents on psychotropic medications were audited for consent forms.
Any resident missing a consent form now has one completed and awaiting signature.
The goal is to obtain all signed consents by [DATE].
Completed consent forms will be uploaded to Epic.
Provider Education: On [DATE], the Medical Director was educated via telephone by the DON on F-F605 regulations, with emphasis on the appropriate use of psychotropic medications. A list of all residents on psychotropics was provided.
The two Nurse Practitioners will be educated on [DATE].
Behavior Monitoring: Behavior logs are reviewed daily during the Interdisciplinary Team (IDT) meeting, including review of care plans for affected residents.
Nurses were previously educated on [DATE] regarding the requirement to implement non-pharmacological interventions prior to initiating psychotropics.
The social worker is aware of this expectation, and the second social worker will be educated on [DATE].
Nursing Education: Re-education for nurses began on [DATE], led by the DON, for all nursing leaders and on-duty staff.
Education will continue throughout [DATE], and no nurse will be permitted to work until this education is completed after [DATE].
Ongoing Monitoring: The DON or designee will pull an Epic report weekly to identify newly prescribed psychotropics and verify that consent forms and monitoring tasks are in place.
New symptoms will be reviewed daily during the IDT meeting and communicated to providers using the SBAR format.
Social Work Education: Social workers were previously educated on obtaining consent for psychotropic medications. On [DATE], one social worker was re-educated by the DON, and the second will be re-educated on [DATE].
Consultant Pharmacist Education: On [DATE], the consultant pharmacist was educated by the DON on the medication review process and verbalized understanding.
235164 10/01/2025
Corewell Health Rehabilitation & Nursing Center - 4368 Cleveland Ave Stevensville, MI 49127
and to outline the required process for post fall follow-up for rehab and nursing centers .A patient fall
on an object (e.g., a trash can).
When a patient rolls off a low bed onto a mat or is found on a surface
to stand or sit and falls back onto a bed, chair, or commode, it is only considered a fall if the patient is injured .Care planning and evaluation will be completed by a licensed nurse who will initiate and update the plan of care and interventions to address risk for falls in the electronic health record (EHR) .Rehab and Nursing Centers: 1.
Assess the resident/patient for injury and circumstances surrounding the injury and determine if the resident/patient can be moved safely. In cases where the resident/patient may not be moved safely, contact appropriate medical providers, staff, or emergency medical response team for assistance. 2.
Evaluate and monitor resident by placing the post-fall assessment order. 3.
Check blood glucose for diabetic patients. 4.
Notify the appropriate individuals including the physician/designee and family members.5.
Review the resident's care plan and update as indicated incorporating interdisciplinary team feedback .
235164 10/01/2025
Corewell Health Rehabilitation & Nursing Center - 4368 Cleveland Ave Stevensville, MI 49127
continuous urinary drainage to an external collection device .Maintain catheter tubing and drainage
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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.