Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northville Manor during CMS and state inspections, most recent first.
The facility did not ensure that posted menus matched the meals actually served, nor did it update or document menu changes when substitutions occurred. Staff and dietary management failed to promptly communicate or post revised menus, and substitution logs were not maintained in a timely manner, affecting nearly all residents who consumed meals from the kitchen.
Surveyors found that the facility failed to maintain a clean and safe environment, with soiled light fixtures, missing safety devices on plumbing, corroded faucets, damaged furniture, and stained carpeting. These deficiencies affected 28 residents and were not addressed through the facility's manual work order and cleaning schedules, as required by policy.
Several residents were not provided a dignified dining experience, as staff were observed standing over residents while assisting with feeding, and meals were served using assorted and inadequate dinnerware such as plastic utensils and small plates. One resident expressed a preference for real silverware over plastic, and some residents experienced delays in starting their meals due to missing utensils or napkins. The facility's policy did not specifically address dignity practices during dining.
The facility did not provide necessary behavioral health care to several residents with severe cognitive and psychiatric diagnoses, as evidenced by extended lapses in psychiatric follow-up and ongoing behavioral symptoms. Staff interviews and record reviews confirmed that psychiatric services were not delivered as required, leaving residents without needed assessments or interventions.
Surveyors found that a medication cart contained 13 loose pills of various types, which had not been properly cleaned or discarded as required by facility policy. Additionally, expired medications, including Geri Lanta and Benadryl, were discovered in the medication storage room, despite staff being responsible for regular checks and removal. These deficiencies were confirmed through staff interviews and review of facility procedures.
CNAs served meals without hair restraints and handled eating surfaces of utensils without gloves, while also passing drinks by holding cups at the rim, leading to potential food contamination for nearly all residents consuming food from the kitchen. The Dietary Manager confirmed these practices were not in line with facility expectations or food code requirements.
Medications ordered to be given at specific times were administered late to several cognitively impaired residents after a nurse was delayed by a medical emergency. The nurse did not notify the DON about the delay, and the DON did not consult the provider regarding the late doses, despite facility policy requiring timely administration and physician involvement in schedule changes.
A resident with adjustment disorder and asthma was not provided with documentation or education regarding influenza and pneumococcal vaccinations. The DON confirmed that the resident's record did not show the vaccine was offered, administered, refused, or contraindicated, despite facility policy requiring annual immunization offers and documentation.
Surveyors identified that several rooms did not meet the required minimum square footage per resident, with multiple rooms housing more residents than the available space allows. Despite interviews revealing no specific complaints or health/safety concerns from residents, the deficiency was confirmed through direct measurement and review of facility records.
A resident with Alzheimer's and severe cognitive impairment was improperly restrained with a sheet by a CNA to prevent her from leaving her chair. The facility lacked documentation for restraint use, violating its restraint-free policy.
A resident with Alzheimer's and other conditions experienced a fall, but the facility failed to update the care plan to reflect this incident. Despite the facility's policy requiring care plan revisions upon status changes, the care plan had not been updated since 2022, and the Director of Nursing acknowledged the oversight.
The facility did not maintain the required RN coverage of eight consecutive hours daily, affecting all 27 residents. Staffing timecards showed gaps in coverage on specific dates, and the DON acknowledged the issue, citing an RN's extended vacation as a contributing factor. The facility's policy mandates RN services for at least 8 consecutive hours per day, 7 days a week.
The facility failed to maintain food service equipment and properly date mark ready-to-eat food, affecting 27 residents. Observations revealed soiled equipment, missing light assembly end caps, and improperly dated milk. These issues violated the 2017 FDA Model Food Code, which requires clean equipment and proper date marking for safety.
The facility experienced deficiencies in internal programs due to leadership changes, affecting all residents. Delays in MDS assessments, inadequate RN coverage, and lack of CNA training were noted. The Infection Control Program was insufficient, with outdated policies and missing documentation. An abuse incident was reported late due to administrative changes. The facility owner acknowledged the issues but was unaware of specific concerns.
The facility failed to implement a comprehensive infection control program, leading to missed corrective actions and potential infection spread. The DON, newly certified as an Infection Preventionist, had not documented infection tracking or antibiotic stewardship since November 2023. The facility's Influenza Vaccination policy was outdated, and the staff call-in log was unavailable. The NHA acknowledged the need for an appointed Infection Preventionist and completion of necessary work.
The facility failed to maintain a clean and safe environment, with observations of accumulated dust, dirt, and debris in common areas and resident rooms. Safety hazards included a loose and rotted handrail and uncovered electrical junction boxes. A resident's room remained soiled over several days, despite being on the cleaning schedule, indicating inadequate housekeeping practices.
The facility failed to submit MDS assessments to CMS on time for six residents due to a backlog caused by the absence of an MDS coordinator for three months. The newly hired LPN acknowledged the delay, with submission deadlines missed for several residents. The facility's policy requires assessments to be transmitted within 14 days of completion, but this was not adhered to, potentially delaying the monitoring of residents' care quality.
The facility did not ensure CNAs completed the required 12 hours of annual in-service education, affecting four CNAs hired between 2021 and 2023. The DON admitted to having no records of such training and acknowledged that no formal in-service trainings had been conducted. The facility's assessment tool confirmed the annual training requirement.
The facility failed to store medications at recommended temperatures and did not consistently document refrigerator temperatures, affecting 12 residents. Medications requiring specific temperature ranges were improperly stored, impacting residents with conditions like glaucoma and diabetes. The DON acknowledged missing documentation and emphasized the responsibility of nurses to maintain temperature logs and report deviations.
The facility failed to obtain consents for immunizations for three residents and did not offer influenza and pneumococcal vaccines to another resident, leading to a deficiency in ensuring informed decision-making and potential spread of infections. Three residents received vaccines without documented consent, and one resident was not documented as having received, been offered, or refused the vaccines.
A facility failed to supervise residents, resulting in a physical altercation between two residents, causing injuries. The incident occurred in an unsupervised dining room during a shift change. One resident, with a history of wandering, was attacked by another resident with known behavioral issues. The facility's policy required staff awareness of residents' needs, but the lack of supervision and failure to separate residents with behavioral issues led to the incident.
The facility failed to report an abuse incident involving two residents to the State Agency within the required timeframe. An LPN intervened in an altercation where one resident was injured, and although immediate actions were taken, the incident was not reported to the state agency until ten days later, contrary to the facility's policy requiring a report within two hours.
A facility failed to monitor the weight of a high-risk resident with cerebral palsy and moderate protein-calorie malnutrition. Despite being on tube feeding, the resident did not have an admission weight recorded, nor were weekly weights documented during the initial weeks of residency, contrary to the facility's policy. This oversight was confirmed by both the RD and DON, highlighting a lapse in monitoring the resident's nutritional status.
A resident expressed dissatisfaction with meals as her food preferences were not honored. She requested vegetables like carrots and green beans, but no alternatives were offered. The Dietary Manager stated that an alternate menu was available, but it was not provided to the resident. The Nursing Home Administrator acknowledged the need for residents to be aware of the always available menu and the lack of follow-through on the resident's requests.
The facility did not have an Infection Preventionist (IP) as a member of the Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) committee for three quarters. The sign-in sheets for meetings in September 2023, January 2024, and May 2024 lacked an IP signature. The previous NHA, who also served as DON, was supposed to fulfill the IP role, but their credentials could not be verified. The current DON received IP certification only after the last QAA meeting, contrary to the facility's policy requiring an IP in the committee.
The facility did not provide the required 80 square feet of space per bed in six resident rooms, with room sizes ranging from 144 to 283 square feet for multiple beds. Despite this, no specific complaints or health/safety concerns were reported by residents.
Failure to Post and Update Menus Following Meal Substitutions
Penalty
Summary
The facility failed to ensure that posted menus accurately reflected the meals served to residents and that menu changes were properly documented and communicated. On one occasion, the posted lunch menu listed braised beef tips, parsley noodles, seasoned carrots, wheat rolls, and Boston cream pie, but residents were instead served hamburgers with buns, lettuce, tomato, onion, pickles, and ice cream. The Dietary Manager explained that a new employee had used the meat intended for a different meal, leading to a last-minute substitution. Although residents were consulted about the substitute menu, there was no evidence that the menu changes were formally posted or that meetings regarding these changes were documented. Further review of the substitution log revealed additional instances where planned menu items were replaced with alternatives, such as potato salad being substituted with potato chips and salmon croquettes being replaced with pizza and salad. These substitutions were not promptly documented, and staff were unaware that posted menus should be updated to reflect changes. Additionally, for special occasions like Easter, planned menu changes were not communicated to residents or posted in advance. No additional evidence was provided by facility leadership to explain the lack of updated or posted menus in accordance with the changes made.
Failure to Maintain Clean and Safe Physical Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's physical environment, including soiled and dirty surfaces, missing safety devices, and worn or damaged furnishings. Specifically, a resident restroom had an overhead light lens cover contaminated with dust, dirt, and dead insects. Another restroom had a corroded and particulate-laden faucet assembly, and a shower room was missing an atmospheric vacuum breaker on the shower wand assembly. The nursing station contained a black vinyl padded chair with exposed inner padding due to wear, and the hallway corridor and day room carpeting were stained, worn, and buckled, with a large red stain noted beneath the resident call system panel. Additionally, several resident rooms had overbed light shades and a stationary desk fan that were heavily soiled with accumulated dust and dirt deposits. Interviews with the Director of Maintenance revealed the facility uses a manual work order system, with the maintenance logbook kept at the nurses station. Review of facility policies indicated requirements for a preventative maintenance program and cycle cleaning schedules to ensure a safe, sanitary, and comfortable environment. However, the observed conditions demonstrated a failure to effectively implement these policies, resulting in unclean and poorly maintained areas that affected 28 residents and increased the likelihood of cross-contamination and bacterial harborage.
Failure to Ensure Dignified Dining Experience and Consistent Use of Appropriate Dinnerware
Penalty
Summary
The facility failed to provide a dignified dining experience for several residents, as evidenced by staff standing over residents while assisting with feeding and serving meals with an assortment of inadequate dinnerware. One resident, who was alert and oriented, expressed dissatisfaction with being served food on plastic plates and using paper and plastic utensils, preferring real silverware. Observations showed plastic ware on the resident's bedside table. During lunch, a nurse was seen standing over a resident while feeding, intermittently leaving to check the medication cart, and placing food in the resident's mouth and hands without consistent engagement. Another resident was observed self-propelling out of the dining room wearing a soiled clothing protector, which was only addressed after the resident returned. Some residents were left without napkins or plastic ware, causing delays in starting their meals and requiring staff assistance to cut food. Further observations revealed that approximately 15 residents were served meals with a mix of Styrofoam cups, dessert plates, plastic utensils, and small melamine plates that were insufficient for the meal portions. The dietary manager confirmed that a full set of dishes was available and the dish machine was operational, but could not explain why assorted dinnerware was used. Staff interviews indicated that the dining room sometimes became crowded, making it difficult to provide one-on-one feeding assistance at an appropriate level. A review of the facility's policy on promoting and maintaining resident dignity showed it did not specifically address dignity practices during dining.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to five out of twelve residents reviewed for behavioral health needs. Multiple residents with diagnoses such as Alzheimer's disease, major depressive disorder, dementia, anxiety, and psychotic disorders had not received timely psychiatric services. For example, one resident with severe cognitive impairment and a history of behavioral symptoms had not been seen by a psychiatric practitioner since August of the previous year, despite being prescribed psychotropic medications and having care plans that called for psychiatric consults as needed. Observations included residents exhibiting behaviors such as yelling out, crying, banging objects, and expressing confusion about their identity, with documentation showing significant lapses in psychiatric follow-up. Several residents had not received psychiatric services for extended periods, ranging from several months to over half a year, despite ongoing behavioral symptoms and care plans indicating the need for such services. Staff interviews confirmed that psychiatric services were not being provided as expected, with the DON and social worker acknowledging the absence of a current psychiatric provider and gaps in service delivery. The lack of psychiatric services was further corroborated by record reviews and staff interviews, which revealed that the facility did not have an active psychiatric group servicing the building for a period of time. This resulted in residents with significant behavioral health needs not receiving the necessary assessments or interventions, as outlined in their care plans and physician orders. The deficiency was identified through direct observation, interviews with staff, and review of medical records.
Failure to Maintain Medication Cart Cleanliness and Timely Disposal of Expired Medications
Penalty
Summary
The facility failed to ensure proper cleaning and disposal of loose medications in one medication cart, as observed during an inspection of the North Hall medication cart. Thirteen loose pills of various shapes, colors, and sizes were found scattered in the drawers of the cart. Interviews with nursing staff and review of facility policy revealed that nurses are expected to clean the cart and discard any loose medications, with the midnight shift specifically assigned this responsibility. However, the presence of loose pills indicated that this procedure was not followed as required by facility policy. Additionally, the facility did not dispose of expired medications in a timely manner. During an inspection of the medication storage rooms, expired medications, including Geri Lanta and Benadryl, were found. The DON confirmed that medication supply staff are responsible for checking and removing expired medications, with weekly and monthly checks expected. Facility policy states that expired medications should be reported to the nurse manager, but the expired items remained in storage, indicating a lapse in adherence to established protocols.
Failure to Ensure Hygienic Practices During Meal Service
Penalty
Summary
Certified Nurse Aides (CNAs) were observed serving meals to residents without using any form of hair restraint or having their hair pulled back, which resulted in the potential for food contamination. Specifically, two CNAs had long, loose braided hair extensions that hung over their shoulders and down their backs, while another CNA with long natural hair was seen repositioning her hair behind her ears to prevent it from touching residents' food. Additionally, this CNA was observed wrapping silverware without wearing gloves and handling the eating surfaces of the utensils while wrapping them in napkins. Another CNA poured beverages and passed drinks to residents by holding the cups at the rim, rather than the base, increasing the risk of contamination. The Dietary Manager confirmed that staff should not have been handling the eating portions of the utensils and that gloves should have been worn during this process. The facility's provided policy, titled "Dress Code," was not specific to food service personnel and only stated that employees with long hair may be required to wear a hair net depending on their duty assignment or work area. The 2009 Michigan Modified Food Code requires food employees to wear hair restraints to prevent hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service articles. These observations affected 27 of the 28 residents who consumed food from the kitchen.
Failure to Administer Medications According to Physician Orders and Scheduled Times
Penalty
Summary
The facility failed to ensure that medications were administered according to physicians' orders and within the scheduled time frames for three residents. Observations showed that a registered nurse administered 9 AM medications to multiple residents several hours after the scheduled time. The medications included Keppra, Metoprolol, Duloxetine, and others, all of which were ordered to be given twice daily at specific times. The nurse reported being delayed due to a medical emergency earlier in the day but did not notify the Director of Nursing (DON) about the delay or seek guidance regarding the late administration of medications. Record reviews indicated that the affected residents had significant cognitive impairments and multiple diagnoses, including seizure disorders, dementia, depression, and heart disease. The facility's policy required medications to be administered within 60 minutes before or after the scheduled time, and any adjustments to the schedule were to be made by a physician. The DON confirmed awareness of the late administration but did not contact the provider to determine if the late doses should be rescheduled. The Nursing Home Administrator stated that the expectation was for medications to be administered as ordered.
Failure to Document and Offer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that a resident was provided with pneumococcal vaccination and education, as well as documentation regarding the influenza vaccine. During interviews, the DON/Infection Preventionist confirmed that there was no documentation in the resident's electronic health record indicating that the influenza vaccine was offered, administered, refused, or contraindicated. The resident in question had diagnoses including adjustment disorder with mixed anxiety and depressed mood, and asthma, and had been admitted to the facility without proper immunization documentation. Further review of facility policy revealed that it requires annual offering and documentation of influenza vaccination or refusal, as well as education about the benefits and side effects of immunization. Despite this policy, the resident's record lacked evidence that the vaccine was offered or that education was provided, and the DON acknowledged that the resident should have been given the opportunity to receive the influenza vaccine for the current flu season.
Resident Rooms Below Required Square Footage Standards
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in six out of fifteen resident rooms, as determined through observation, interviews, and record review. Specifically, rooms were found to have less than 80 square feet per resident in multiple occupancy rooms and less than 100 square feet in single occupancy rooms. The review of facility bed count information with the Nursing Home Administrator confirmed that several rooms, including those with two to four beds, did not meet the required space standards. Although residents interviewed did not express specific complaints or health and safety concerns, the deficiency was identified based on the physical measurements and occupancy of the rooms.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to prevent the use of physical restraints on a resident, identified as R401, who was observed sitting in a chair with a sheet wrapped around her waist and tucked behind the chair, effectively restraining her. This incident was reported by a CNA who found the resident in this condition. The resident, who has a history of Alzheimer's disease and severe cognitive impairment, was unable to answer questions due to confusion. The CNA involved admitted to wrapping the sheet around the resident to prevent her from getting up, as the resident was entering other residents' rooms and not following instructions. The facility's records revealed no orders, consents, assessments, or care plans for the use of restraints on R401. The facility's policy, which was implemented in November 2022, states that the environment should be restraint-free unless there are medical symptoms that warrant restraint use. The Nursing Home Administrator and Director of Nursing confirmed that the facility is supposed to be restraint-free and acknowledged the lack of documentation supporting the use of restraints for R401.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise the care plan for a resident in a timely manner following a fall incident. The resident, who has Alzheimer's disease, adjustment disorder with mixed anxiety, depressed mood, and major depressive disorder, was admitted to the facility with severely impaired cognition. An incident report was submitted to the State Agency after the resident sustained an injury of unknown origin, and it was noted that the resident had a slight discoloration under the left eye. Despite a fall occurring on 12/10/2024, the resident's care plan, which was last reviewed on 12/8/2024, had not been updated since 9/6/2022 to reflect this incident or any new interventions. The Director of Nursing acknowledged that the care plan should have been updated to include the recent fall and any necessary changes to the resident's care. The facility's policy requires that care plans be reviewed and revised when a resident experiences a status change, involving notification of the MDS Coordinator, physician, and resident representative, if applicable. The policy also outlines the procedure for updating care plans, including team discussions, documentation, and communication of interventions to staff. However, these steps were not followed in this case, leading to the deficiency.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, which is a requirement for adequate coordination of care. This deficiency affected all 27 residents in the facility. The issue was identified through a review of staffing timecards, which revealed that there was no consecutive 8-hour RN coverage on specific dates in April and May 2024. During an interview, the Director of Nursing (DON) acknowledged the staffing problem and mentioned that another RN, who usually worked midnights and weekends, was on an extended vacation. The DON confirmed that they had recently hired another RN to help cover the shifts when the DON was not working. The facility's policy requires the utilization of RN services for at least 8 consecutive hours per day, 7 days a week.
Deficiencies in Food Service Equipment Maintenance and Date Marking
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment and properly date mark potentially hazardous ready-to-eat food products, affecting 27 residents. During an initial tour of the food service area, a half-gallon of Prairie Farms whole milk was found in the Traulsen 2-door reach-in cooler without an open or out date, despite having a manufacturer's use-by-date of May 26. The Dietary Manager stated that products are date marked when opened for a total of 7 days, if the manufacturer's use-by-date allows. This practice did not comply with the 2017 FDA Model Food Code, which requires ready-to-eat, time/temperature control for safety food to be clearly marked for consumption, sale, or disposal within 7 days when held at 5°C (41°F) or less. Additionally, several pieces of food service equipment were observed to be heavily soiled. The Traulsen 2-door reach-in cooler and freezer door gaskets, the can opener assembly mounting plate, the Ice-O-Matic ice machine interior plastic resin retention plate, and the garbage disposal overhead spray valve assembly were all noted to have accumulated and encrusted dirt, dust, and food debris deposits. These conditions violated the 2017 FDA Model Food Code, which mandates that equipment food-contact surfaces and utensils be clean to sight and touch, and that non-food-contact surfaces be free of dust, dirt, food residue, and other debris. Furthermore, 11 of 24 overhead light assembly end caps were missing, which is a violation of the 2017 FDA Model Food Code that requires light bulbs to be shielded, coated, or otherwise shatter-resistant in areas with exposed food, clean equipment, utensils, and linens. The basement's Kelvinator refrigerator interior flooring surface was also severely corroded and particulate, with a new refrigerator on order. The facility's policies and procedures for sanitation inspections and ice machine maintenance were reviewed, revealing that the facility aims to keep food service areas clean and sanitary, and to ensure ice machines are properly maintained to prevent microbial contamination.
Leadership Changes Lead to Deficiencies in Internal Programs
Penalty
Summary
The facility failed to maintain continuity of internal programs during leadership changes, affecting all 27 residents. The Minimum Data Set (MDS) assessments were delayed due to the absence of an MDS Coordinator for about three months, resulting in assessments being over 120 days late for several residents. The Nursing Home Administrator (NHA) acknowledged the lapse and the need for timely completion and submission of MDS assessments in accordance with state regulations. Staffing issues were also identified, with the Director of Nursing (DON) acknowledging the lack of consecutive 8-hour Registered Nurse (RN) coverage. The facility had recently hired another RN to address this issue, but the DON admitted there was a problem with staffing. Additionally, the facility failed to provide the required 12-hour Certified Nurse Assistant (CNA) in-service and competencies training, including abuse and dementia training, as there were no records from the previous DON, and no formal in-service training had been conducted by the current DON. The facility's Infection Control Program was found to be lacking, with documentation of infection identification, tracking, monitoring, and antibiotic stewardship ending in November 2023. The DON, who became certified as an Infection Preventionist in May 2024, was unaware of the location of the staff call-in log. The facility's Influenza Vaccination policy had not been updated since November 2022. Furthermore, there was an eleven-day delay in reporting a resident-to-resident abuse incident to the State Agency, which the NHA attributed to administrative changes during that period. The facility owner/CEO acknowledged the leadership changes and the need for improvement but was unaware of specific concerns due to a lack of communication.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to consistently implement a comprehensive infection control program, which resulted in missed opportunities for corrective actions and the potential spread of infectious organisms throughout the facility. The Director of Nursing (DON), who was also the Infection Preventionist, had only recently received certification on 5/20/24, and the previous Infection Preventionist's employment ended in November 2023. Since then, there had been no documentation regarding infection identification, tracking, monitoring, analysis of surveillance data, responding follow-up activity, or antibiotic stewardship. Additionally, the facility's Influenza Vaccination policy had not been updated since 11/1/22, and the staff call-in log, which documents the staff's reasons for calling in, was unavailable for review. The DON was unable to locate or access this log. The Nursing Home Administrator acknowledged that an Infection Preventionist should have been appointed and the necessary work completed. The facility's policy on the Infection Prevention and Control Program, dated 3/13/24, outlined the need for a system of surveillance and an antibiotic stewardship program, but these were not being effectively implemented.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, staff, and the public, as evidenced by several observations during an environmental tour. The common areas, including a resident restroom, dining room, and day room, were found to have accumulated dust, dirt, and debris, indicating inadequate cleaning practices. Additionally, the front entrance handrail was loose and rotted, posing a safety hazard. The laboratory specimen refrigerator was also improperly maintained, with soiled surfaces and an incorrect temperature reading, which could compromise the integrity of stored specimens. Further deficiencies were noted in the resident rooms, where issues such as damaged drywall, uncovered electrical junction boxes, loose fixtures, and non-functional lighting were observed. One room was described as extremely malodorous, suggesting a lack of proper sanitation and ventilation. These conditions were not documented in the maintenance log, indicating a failure in the facility's maintenance tracking and response system. The facility's policies on cycle cleaning and environmental inspections were not effectively implemented, as evidenced by the persistent cleanliness issues. A specific resident's room remained soiled over several days, despite being on the cleaning schedule, highlighting a gap in housekeeping execution. The housekeeper responsible for cleaning expressed difficulty in managing her workload, which may have contributed to the ongoing cleanliness issues in the facility.
Delayed MDS Submissions
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were signed and submitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for six residents. This deficiency was identified during an interview and record review, revealing that the facility was significantly behind in MDS submissions due to the absence of a dedicated MDS coordinator for approximately three months. The newly hired Licensed Practical Nurse (LPN) and MDS Coordinator, who started on March 25, 2024, acknowledged the backlog and confirmed that several assessments were overdue for submission. The specific residents affected by this delay included Resident #2, Resident #12, Resident #15, Resident #20, Resident #21, and Resident #22, with submission deadlines ranging from March 30, 2024, to May 6, 2024. The facility's policy, dated February 23, 2024, mandates that all assessments be transmitted to the designated CMS system within 14 days of completion. The Nursing Home Administrator expressed expectations for timely submissions to comply with state regulations and facility policies. However, the lack of a timely submission process resulted in a delay in monitoring the quality of care provided to the residents and potentially delayed the identification of health concerns.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) completed the required 12 hours of in-service education annually, affecting four out of five CNAs reviewed. The CNAs in question were hired between June 2021 and September 2023, and there was no evidence of the required training being provided by the facility. During an interview, the Director of Nursing (DON) acknowledged the absence of records for the 12-hour in-service training and admitted that no formal in-service trainings had been conducted since taking over the role. The facility's assessment tool, updated in May 2024, confirmed the requirement for CNAs to receive at least 12 hours of in-service training annually to ensure their continuing competence.
Improper Medication Storage and Documentation
Penalty
Summary
The facility failed to store biologicals and medications at the recommended temperature parameters for 12 residents and did not consistently document refrigerator temperatures for 27 residents. Observations revealed that the medication refrigerator temperature was at 32 degrees Fahrenheit, which is below the recommended range of 36 to 46 degrees Fahrenheit for certain medications. The temperature monitoring logs from January to May 2024 showed multiple omissions and instances where temperatures were recorded below the recommended range. The medications affected included Latanoprost Ophthalmic Solution, Influenza Vaccine, Tuberculin Purified Protein Derivative, Pneumococcal Vaccine, and various insulin products, which require storage between 36 and 46 degrees Fahrenheit. Additionally, medications like Refresh Tears and Brimonidine Tartrate Ophthalmic Solution, which should be stored between 58 and 86 degrees Fahrenheit, were also improperly stored. The residents affected had various medical diagnoses, including glaucoma, type 2 diabetes mellitus, and age-related nuclear cataract, and were prescribed these medications as part of their treatment. The Director of Nursing acknowledged the missing documentation and stated that it was the nurses' responsibility to fill out the temperature log daily and report any deviations to maintenance. The facility's policy on medication storage requires staff to report improper storage temperatures and not administer medications exposed to such conditions. However, the failure to adhere to these procedures led to the deficiency in medication storage and documentation.
Failure to Obtain Vaccine Consents and Offer Immunizations
Penalty
Summary
The facility failed to obtain consents for immunizations for three residents and did not offer influenza and pneumococcal vaccines to one resident, leading to a deficiency in ensuring informed decision-making and potential spread of infections. Specifically, three residents, who were all over the age of 65, received vaccines without documented consent. Resident #6 and Resident #8 received the influenza vaccine, while Resident #10 received both the influenza and pneumococcal vaccines, all without proper consent documentation. Additionally, Resident #18, who had been in the facility during the previous flu season, was not documented as having received, been offered, or refused the influenza and pneumococcal vaccines. The facility's policies required signed consent forms for vaccinations, which were not adhered to in these cases. The Nursing Home Administrator acknowledged the need for completed consent forms to ensure evidence of consent and education, but no additional documentation was provided to address these deficiencies.
Failure to Supervise Residents Leads to Physical Altercation
Penalty
Summary
The facility failed to supervise residents adequately, leading to a physical altercation between two residents, resulting in one resident sustaining physical injuries. The incident occurred in the dining room during a shift change when a Licensed Practical Nurse (LPN) heard a commotion and found one resident grabbing and scratching another. The LPN intervened to stop the altercation. Interviews revealed that the dining room was unsupervised at the time, and the facility was aware of the behavioral issues of the involved residents. One resident had a history of wandering and getting into others' personal space, while the other had past behavioral issues, including verbal yelling and physical aggression. The involved residents had significant medical histories, with one diagnosed with Alzheimer's Disease and Major Depressive Disorder, and the other with Schizoaffective Disorder, Altered Mental Status, Dementia, and Anxiety. The facility's policy on abuse, neglect, and exploitation emphasized the need for staff to be aware of residents' care needs and behavioral symptoms. However, the lack of supervision in the dining room and the failure to separate residents with known behavioral issues contributed to the incident, highlighting a deficiency in the facility's ability to prevent abuse and ensure resident safety.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to report an incident of abuse to the State Agency in a timely manner for two residents involved in an altercation. On the evening of March 16, 2024, an LPN heard a commotion in the dining room and observed one resident grabbing another by the shirt, resulting in scratches and hits to the face, leaving multiple abrasions on the chest and face of the victim. The LPN intervened to stop the altercation, and the Director of Nursing, emergency contacts, and physician were notified. Both residents were separated and assessed for injuries, and the local police were contacted shortly after the incident. Despite the immediate actions taken to address the situation, the Nursing Home Administrator did not report the incident to the state agency until ten days later, on March 26, 2024. The facility's policy requires that any allegations involving abuse or resulting in serious bodily injury be reported within two hours of discovery. The delay in reporting this incident was acknowledged by the Nursing Home Administrator during an interview, confirming that the expectation was not met according to the facility's policy.
Failure to Monitor Weight for High-Risk Resident
Penalty
Summary
The facility failed to ensure proper weight monitoring for a resident identified as being at high nutrition risk. The resident, who has cerebral palsy, dysphagia, and moderate protein-calorie malnutrition, was observed receiving tube feeding. Despite being at high risk, the facility did not obtain an admission weight, nor did they record weekly weights during the resident's initial weeks at the facility. This lack of monitoring was confirmed by both the Registered Dietitian and the Director of Nursing, who acknowledged that the resident should have had documented weights upon admission and weekly thereafter for four weeks. The facility's policy on weight monitoring, dated March 27, 2024, specifies that weights should be recorded at the time obtained and that newly admitted residents should have their weight monitored weekly for four weeks. However, this policy was not followed for the resident in question, as evidenced by the absence of recorded weights during the critical initial period of residency. This oversight resulted in a potential delay in identifying any undesirable changes in the resident's weight status and compromised their nutritional status.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, leading to dissatisfaction with meals. On the specified date, the resident was observed with a lunch tray that did not meet her preferences. Although she expressed a liking for vegetables and requested alternatives such as carrots and green beans, no meal alternative was offered. The resident reported not receiving the requested vegetables and was not informed of available food items that could be requested as alternatives. The Dietary Manager indicated that residents could order from an alternate menu, but this menu was only posted in the dining room and not provided to the resident. The resident's meal ticket noted a preference for vegetables, but no dislikes were listed. The Nursing Home Administrator acknowledged that residents should be aware of the always available menu, and there should have been follow-through on the resident's requests for specific vegetables. The facility did not provide any additional documentation or information before the end of the survey.
Infection Preventionist Absence in QAA Committee
Penalty
Summary
The facility failed to meet the requirement for having an Infection Preventionist (IP) as a member of the Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) committee for three consecutive quarters. During a review of the QAA/QAPI quarterly meeting notes, it was found that the sign-in sheets for the meetings held in September 2023, January 2024, and May 2024 did not include a signature from an IP. The Nursing Home Administrator (NHA) explained that the previous NHA, who also served as the Director of Nursing (DON), was supposed to fulfill the IP role. However, the Business Manager and Human Resource Director were unable to verify the IP credentials for the previous Administrator and DON, as they could not be located in the records. Further investigation revealed that the current DON, who was expected to hold the IP certification, did not have it at the time of the last QAA meeting on May 15, 2024. The DON confirmed that the IP certification was only awarded on May 20, 2024, after the meeting had taken place. The facility's policy on QAPI, which was implemented on November 1, 2022, mandates that the QAA committee must include an IP among its interdisciplinary members. The absence of an IP in the committee for the specified quarters potentially impaired the facility's ability to effectively resolve infection control and prevention issues, affecting the quality of care for all 27 residents in the facility.
Facility Fails to Meet Space Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the required 80 square feet of space per bed in six of the 33 resident rooms, specifically rooms 2, 7, 10, 11, 12, and 14. Observations and record reviews revealed that room 2 had 283 square feet for 4 beds, room 7 had 218 square feet for 3 beds, room 10 had 225 square feet for 3 beds, room 11 had 215 square feet for 3 beds, room 12 had 154 square feet for 2 beds, and room 14 had 144 square feet for 2 beds. Despite these deficiencies, interviews with various residents did not reveal any specific complaints or health/safety concerns related to the space provided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Northville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Manor Of Novi | 3.1 mi | ★★★★★ | 22 | 0 |
| Wellbridge Of Novi | 3.8 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Plymouth | 4.4 mi | ★★★★★ | 0 | 0 |
| Marywood Nursing Care Center | 4.5 mi | ★★★★★ | 5 | 0 |
| Novi Lakes Health Campus | 4.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.