The inspection at Pavilion at Glacier Valley, completed October 8, 2025, traced what happened after a hospice nurse visited on the morning of September 6.
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Immediate jeopardy means inspectors have determined that the failure is likely to cause serious injury or death if it isn't fixed.
Both incidents happened at The Springs at Rochester Hills Rehab and Nursing Center.
The jeopardy period ran from September 1 through September 3.
The chemical was not smuggled in.
A cognitive assessment conducted in August gave her a score of six out of 15, indicating severe impairment.
She did not investigate how long they had been missing or what residents in that room had experienced in the meantime.
The incident happened September 28, 2025 at Greenfield Rehab and Nursing Center.
That is what federal inspectors found when they visited the facility on October 3, 2025, responding to a complaint.
The incident happened during lunch service on October 1, 2025.
The first incident occurred during a Hoyer lift transfer.
The October 7 inspection found three of the facility's four treatment carts unlocked and unattended across two floors.