Notting Hill Of West Bloomfield

F 0610 Level of Harm - Minimal harm or potential for actual harm

they did not have any additional information regarding the skin tear and also volunteered knowledge of Unit Manager 'J' turning in their two-week notice saying their last day of work was coming up. A review of a facility provided policy titled, Abuse Prohibition Policy revised 9/2022 was conducted and defined Injuries of unknown source, however; the policy did not address investigating, Injuries of unknown source.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Notting Hill of West Bloomfield

6535 Drake Rd West Bloomfield, MI 48322

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake 2660427.Based on interview and record review, the facility failed to provide care for a cholecystostomy tube (biliary drainage tube inserted into the gall bladder to relieve symptoms of gall bladder disease) consistent with professional standards and in accordance with Physician orders for one (Resident R704) of one resident reviewed with a cholecystostomy (biliary) tube resulting in a delay of surgical intervention to exchange Resident R704's biliary catheter.Findings include:A complaint was filed with the State Agency on 10/31/25 alleging the facility did not provide care for a cholecystostomy biliary drain consistent with professional standards and in accordance with Physician orders. On 11/25/25 at 9:26 AM, a telephone

interview with Resident R704's family (complainant) confirmed on October 11, 2025, while visiting with Resident R704 they had observed drainage from the area of the biliary drain which grossly soiled Resident R704's linens and clothing.

The family had to get a nurse at which time they observed the nurse reinforcing the area with gauze and never assessed underneath the dressing. On 10/15/25, Resident R704 had an appointment at the hospital to exchange their biliary drain. The Physician stated the drain was no longer placed internally but was outside of his body and could not be replaced as scheduled because the internal tract had closed. The Physician informed the family, based on the closure, it was estimated the tube was dislodged for at least three days.

The surgery had to be rescheduled and would require Resident R704 to undergo an abdominal CT (computed tomography) scan (X-ray with detailed cross-sectional images) with contrast (special dye administered to highlight vessels, organs, and tissues) prior to replacing the biliary tube. The family indicated they could not recall the name of the nurse from 10/11/25 but did inform the Director of Nursing (DON) who would further

review what happened.Clinical record review revealed Resident R704 was a long-term resident of the facility since June 2019 and was last readmitted on [DATE REDACTED]. Resident R704 had end stage renal disease and was on hemodialysis three times a week. Resident R704 had a cholecystostomy tube related to their gall bladder disease. A review of the Medical Data Set (MDS) assessed on 10/29/25 documented Resident R704 had severely impaired cognition.Record

review of the Interventional Radiologist Physician consultation dated 10/15/25 documented that Resident R704 .presented for chole (cholecystostomy) tube exchange.TUBE WAS DISLODGED, TRACT WAS CLOSED.We were unable to replace tube at this time.Previous exchange cystic duct was open.Please get abdominal CT with contra <sic> in 10-14 days.Record review of Resident R704's October 2025 Treatment Administration Record (TAR) documented .Change Biliary dressing once daily.Every shift.Drain Biliary Drain every shift and document the amount every shift.The TAR was reviewed for the month of October 2025 and revealed that a consistent pattern from 10/1/25 to 10/15/25, nursing did not document their assessment of the drain every shift, except for 10/5/25.On 11/25/25 at 3:00 PM, the DON was interviewed and recalled their familiarity with the incident. The DON was updated that during the interview with the family, the Physician at the hospital had identified on 10/15/25 the tube had been outside of the body for at least three days. The DON reviewed the October 2025 TAR and nursing should have identified zero output dated 10/12/25, 10/13/25, 10/14/25 from the drain was abnormal. When asked how on 10/15/25 there was documentation of 60 milliliter (ml) of drainage upon record review of the TAR by the day shift Nurse H, the DON indicated they had discussed the same concern with Nurse H and once confronted of the documented drainage on a tube that was not in place, Nurse H became upset told the DON they did not have to deal with this, and quit. The DON acknowledged that Nurse H had falsified their documentation, and

this was a concern.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet