The resident at WellBridge of Novi had been readmitted with acute congestive heart failure, blood clots in both legs, and swelling throughout her body.
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The admission assessment at Oakmont Healthcare and Rehabilitation Center of Katy showed no documented weight for the resident on August 29, 2025.
Inspectors classified the violations as having "minimal harm or potential for actual harm" affecting "some" residents.
Resident #2 left the facility grounds and walked to his previous residence, where his son found him.
Resident #117 disappeared from Greenbrier Health Center sometime after 10:30 p.m.
Federal inspectors discovered the unauthorized room change during an October complaint investigation.
Primary Care Physician 500 told inspectors he was never informed about the medication discrepancies.
The October 7 incident at Omaha Nursing and Rehabilitation Center involved treating a softball-sized stage four pressure ulcer on the resident's sacrum.
The resident died with conflicting instructions in their medical record.
The facility's administrator didn't notify proper authorities until October 7 — six days after the abuse occurred.
The incident occurred at Brittany Manor on September 14, 2025, at 3:30 PM in the activity room.
The resident reported a pain level of 8 out of 10 throughout the ordeal.