Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 The Manor Of Novi during CMS and state inspections, most recent first.
A facility failed to prevent avoidable falls and provide adequate supervision for residents. A bedbound resident with dialysis dependence fell from bed after a CNA left them on their side without support and later sustained a shoulder fracture requiring hospital care. Two other residents fell when a wheelchair seatbelt was left unfastened and when a bed was left in the wrong position, and two wandering residents were not adequately redirected when one entered another resident's room.
A resident admitted with osteomyelitis, toe amputations, IV antibiotics via PICC, and AKI on hemodialysis had a sacral Stage III pressure injury that was not identified on admission. The DON acknowledged the admission LPN did not complete a thorough skin assessment, the wound care specialist was not formally consulted until the resident self-reported the wound, and later the coccyx wound was observed without a dressing in place after the resident said it had been soiled earlier and not redressed.
Insufficient Nursing Staffing and Delayed Resident Care: Residents reported long waits for call light response, delayed incontinence care, missed or late assistance with meals, and lack of fresh water, especially at night and on weekends. Multiple residents said staffing was too low, with CNAs covering too many residents and nurses covering multiple units or not present at the start of a shift. Interviews with staff and the DON confirmed call-ins, short staffing, and a shift with no nurse assigned for part of the evening.
Food Storage and Sanitation Deficiencies: An opened container of hummus and an opened package of sliced cooked turkey breast were found past the facility-marked use-by dates in the upright cooler. Two hydration carts had soiled, non-removable mesh ice scoop storage bags that were uncovered and exposed to contamination, one was frayed and torn, and additional sanitation issues were observed with a soiled ice machine bin drain line and dust buildup on kitchen ceiling tiles.
Staff failed to maintain resident dignity during care and meals. A resident was transported to the shower room facing rearward in a shower chair, staff were overheard referring to residents as “feeders,” a CNA provided 1:1 feeding while scrolling on a cell phone, two residents were seated at tables set too low for them, an LPN stood over a resident while assisting with breakfast, and an unknown staff member talked on a cell phone and discussed personal business in the hallway while transporting a resident.
An LPN prepared and administered medications for two residents at the same time, and the DON confirmed nurses should not prepare medications for different residents together. The facility also had conflicting diet orders for a resident receiving tube feeding and pleasure feeding, with food and orange juice served despite unclear NPO and PO orders. In addition, a resident had undated forearm dressings with bruising visible underneath, and the skin beneath the dressings was not assessed.
Failure to assess and treat multiple left lower leg skin openings: A resident with severe cognitive impairment and a history of kicking the left leg had a documented skin tear that was not properly assessed or tracked, and later multiple open areas were observed on the left lower leg. Staff did not document a complete wound assessment, the treatment nurse did not examine the leg, and ordered tubi grip was not observed on the resident’s legs during observations. The DON acknowledged the physician’s orders should have been followed.
A resident with intact cognition and an infected tooth had repeated reports of severe mouth/jaw pain, but ordered antibiotics were missed and the opioid pain medication was discontinued despite ongoing 10/10 pain. Dental services documented decayed teeth and recommended extraction plus antibiotics, yet the resident continued to report pain and there were no notes showing the MD was contacted about the excessive pain. The DON acknowledged the missed doses and uncertainty about why the pain medication was stopped.
Failure to Provide Fresh Water Consistently: Multiple residents reported not receiving fresh water every day, and several were observed with empty or stale water cups dated from the prior day. Residents said they had to ask repeatedly for water, including at night, and that staff sometimes refused because the CNA was assigned to the roommate. The DON stated water was passed each 12-hour shift with no required time, and resident council minutes documented repeated concerns about not receiving fresh water daily.
Resident council grievances were not promptly resolved, with multiple residents reporting ongoing problems with fresh water, staff not returning after answering call lights, CNAs using phones or earbuds during care, short staffing, wandering residents entering rooms, delayed incontinence care, and dirty rooms and bathrooms. Council minutes showed repeated complaints over several months, and residents said the issues continued despite being raised in council and to facility leadership.
Medication Not Administered Per Order: A resident with peripheral vascular disease, heart disease, and dementia did not receive ordered Pregabalin 100 mg at bedtime for several days after readmission. Medication notes showed the drug was waiting on pharmacy delivery, while the DON stated she was unaware the medication had not been given, did not run audits, and later acknowledged the back-up supply contained Pregabalin 100 mg that could have been used.
Call Light Not Kept Within Reach: A resident with intact cognition, diagnoses including DiGeorge Syndrome, severe depressive disorder, and bacterial infection, was observed on two occasions reporting pain and needing assistance while their call light was out of reach. The resident stated they could not use the call light for help, and the DON was informed that staff should ensure call lights are in reach.
A facility failed to maintain a clean, comfortable, and homelike environment for two residents. One resident, with sarcoidosis and impaired decision-making, had a wall clock that remained stuck at 8:50 during repeated observations, and the resident said it was important to know the actual time. Another resident, with COPD and impaired cognition, reported having to clean her own bathroom and make her own bed at times; the bathroom was observed with a urinal coated with dried brown substance, a trash can full of soiled briefs with visible fecal matter, and a toilet with dried brown substance on it.
A resident with diagnoses including dementia, CKD, DM, depression, and anxiety was observed in a wheelchair with a seatbelt restraint fastened during room time, a music activity, and lunch. The physician’s order required the seatbelt to be released q2h and during supervised meals and activities, but the restraint remained in place during these observations, and the DON stated the facility had no place to document restraint release.
Failure to provide ordered 1:1 feeding assistance and oral hygiene. A resident with dysphagia, sarcoidosis, and moderately impaired cognition was observed with thick oral residue and reported staff did not often help brush their teeth. The resident had an order for pureed/thin pleasure feeding with 1:1 assist, but a CNA left the meal tray in front of the resident without staying to assist, and the care plan/Kardex did not reflect the updated 1:1 feeding intervention. The resident’s care plan also directed staff to assist with oral hygiene, including brushing.
A resident with osteomyelitis, toe amputation, AKI, and hemodialysis had a PICC for IV antibiotics, but staff failed to assess the continued need for the line after antibiotics ended. The resident reported the PICC had not been used in a while, would not flush, and was uncomfortable; the site was observed with a dated dressing, rolled edges, dried blood at the insertion site, and dried blood in the lumen. Nursing leadership acknowledged the PICC should have been addressed sooner.
The facility failed to ensure that two CNAs had documented new hire and annual competency evaluations, as well as 1:1 training related to falls and transfers. One CNA left a bedbound resident alone on their side while placing a bedpan, and the resident rolled off the bed and sustained a L shoulder fracture; the other CNA’s file lacked yearly competency review documentation.
Failure to implement EBP for a resident with an unstageable coccyx pressure ulcer, osteomyelitis, a PICC line for IV antibiotics, AKI, and hemodialysis. During a dressing change, no EBP signage or PPE was posted outside the room, and an LPN used only gloves. The LPN did not think the resident needed EBP, while the Infection Control RN stated residents with pressure wounds requiring dressing changes do qualify for EBP and could not explain why the resident was not on EBP.
A resident with diabetes, ESRD, hemodialysis, limited mobility, and Hoyer lift use sustained skin tears after an argument with a CNA over getting up and dressed. Staff documented open areas and later described neck, arm, and other skin tears, but the investigation relied on assumptions that the Hoyer sling caused the injuries and did not thoroughly address the circumstances, contributing factors, or a formal review with the involved staff and resident.
A resident admitted for hospice respite care with dementia, chronic respiratory failure, and a history of falls had no documented shoulder issues on admission or during an early skin check, but at discharge staff identified a purplish/yellow discoloration on the upper shoulder. Hospice CNAs later reported that bruising was not initially present but was observed on a subsequent visit, and imaging after discharge showed a healed or healing nondisplaced femoral neck fracture. Facility staff, including the DON and Administrator, were unable to determine the cause of the shoulder bruise, completed an IA report, and acknowledged that the injury was of unknown origin, yet they did not report this injury to the State Agency as required by the facility’s abuse/neglect reporting policy.
A resident who had previously reported a conflict with a CNA and requested not to be assigned to that caregiver was nonetheless assigned to the same CNA on multiple occasions. Facility staff confirmed the resident's complaint and acknowledged that the CNA should not have been assigned to the resident, but staffing records and care documentation showed otherwise, resulting in resident dissatisfaction and a complaint to the State Agency.
A resident reported a conflict with a CNA and requested not to have that CNA assigned to their care. Despite this request and facility policy requiring staff to assist with grievance documentation, the CNA was reassigned to the resident and no grievance form was completed or filed.
The facility failed to maintain sanitary conditions in the kitchen and on the C hall medication cart. Observations revealed pooled milk and blood in the walk-in cooler, improper storage of raw meats, and uncovered utensils. Additionally, a water pitcher on the medication cart was not changed as per facility policy, with staff admitting to a lack of standard procedure for changing pitchers.
The facility did not protect the personal health information of nine residents, as their names and dialysis schedules were visible on a bulletin board at the nursing station. The Director of Nursing confirmed that the schedules were posted without a privacy cover, violating the facility's HIPAA policy on confidentiality.
The facility failed to ensure appropriate use of restraints for two residents. One resident was unable to exit a Merry Walker independently, indicating it functioned as a restraint, while another had a seatbelt that was not released as required by their care plan. The facility's restraint management policy was not followed, and there was no documentation of restraint release or consent.
A resident with multiple infections and a midline IV did not have a comprehensive care plan addressing their use of antibiotics and current diagnoses. Despite being on IV antibiotics for a UTI and pneumonia, the care plans were not updated, and the only existing plan was for being at risk for a UTI. Interviews with the Infection Preventionist and DON revealed a lack of responsibility and adherence to the facility's care planning policy.
A nurse in an LTC facility failed to provide care according to professional standards by inaccurately informing a resident about the contents of their medication cup. The nurse did not include Tylenol in the cup but told the resident that a different pill was Tylenol. This was confirmed by the DON, who stated that the nurse should not have misinformed the resident.
The facility failed to provide routine showers and hygiene care for two residents as per their scheduled care plans. One resident, with moderate cognitive impairment, reported not receiving a scheduled shower, and the EMR confirmed infrequent showers with no documented refusals. Another resident was observed with poor hygiene despite documentation indicating care was provided. The DON confirmed the lack of documentation and was informed of the residents' conditions.
A resident with diabetic ulcers did not receive daily wound care as ordered, with dressings observed unchanged for two days. The treatment was incorrectly signed off as completed, despite the resident's confirmation of missed care. The DON acknowledged the requirement for adherence to physician's orders.
The facility failed to prevent accidents for two residents, resulting in a fall and potential injuries. One resident was found on the floor due to an improperly secured seatbelt, while another was unsafely transported in a shower chair facing rearward. The Director of Nursing confirmed these actions were against facility policy.
The facility exceeded the acceptable medication error rate with two errors involving two residents. One resident received an incorrect calcium supplement, while another received Dorzolamide eye drops in both eyes instead of just the left. The errors were attributed to not following physician orders and medication administration protocols.
A facility failed to obtain physician-ordered x-rays for a resident with pain in the right shoulder and hips. The resident, who had type 2 diabetes, insomnia, and end-stage renal disease, had an x-ray order dated 12/28/24, but no documentation showed the x-rays were completed. The DON stated that STAT orders are usually completed within 4 to 6 hours, and general orders are set for three days to avoid being missed, yet the x-ray was not done.
Two residents were at risk due to a sharp metal strip on their doorway frame, which was not identified by the facility's maintenance or reporting systems. The Unit Manager and Maintenance Director were unaware of the issue until it was highlighted during a survey, despite regular environmental rounds and audits.
A resident reported that a package containing pharmacy items was opened and partially missing when delivered to their room, violating their right to receive unopened mail. The facility's Administrator confirmed the package was mistakenly opened by staff, contrary to the facility's policy that mail should be delivered unopened unless otherwise indicated by the resident.
A facility failed to notify the wound care practitioner and update interventions for a resident with a stage IV pressure wound. Despite a treatment plan by the DON, no further interventions were implemented, and the wound worsened, leading to hospitalization. Staff interviews revealed a lack of awareness and communication regarding the resident's wound care needs.
A resident with severe cognitive impairment frequently wandered into other residents' rooms, leading to an incident where another resident, feeling threatened, hit them on the head. Despite interventions like stop signs and a wander-guard, staff were unable to consistently redirect the wandering resident, resulting in a failure to protect residents from abuse.
A resident with no prescribed narcotics was found unresponsive and required Narcan, raising concerns about a possible medication error. Another resident with severe cognitive impairment and a history of wandering exited the facility through a fire exit door, highlighting inadequate supervision and intervention. Staff were aware of the behaviors but were not always present to redirect the resident.
A resident was found unresponsive and given Narcan by EMS, suggesting opioid presence. Despite a physician's order for a urine drug test, the facility failed to collect the sample. The ADON stated the nurse couldn't obtain it, and the order was marked completed automatically. The resident had diagnoses including COPD, depression, and dementia, and showed symptoms indicating possible opioid use, but no test was conducted to confirm.
Falls and Supervision Lapses
Penalty
Summary
The facility failed to prevent avoidable falls for three residents and failed to provide adequate supervision for two wandering residents. One resident, who was cognitively intact, bedbound, non-ambulatory, and admitted with acute kidney failure, morbid obesity, and dialysis dependence, reported that after a CNA turned them onto their side to use a bedpan and left the room, they slipped off the bed while waiting for help and landed on the floor. The resident stated they had no assist bars in place at the time and that their call light became tangled underneath them. They were later transferred to the hospital and diagnosed with a comminuted minimally displaced humeral head fracture and pain in the left shoulder and arm. Facility records and interviews confirmed the resident was at risk for fall-related injury and required total assistance for transfers and bed mobility. The incident report documented that the resident was found on the floor with left shoulder pain and was sent to the hospital. The CNA involved stated they left the room for about 15 minutes after placing the resident on their side, and an RN later stated the CNA should never have left the resident alone because the resident was bedbound, obese, and had nothing to hold on to while on their side. The record also showed no documentation that the CNA had received initial training or 1:1 training related to the incident, despite staff stating education had been provided. The facility also failed to ensure supervision for two residents. One resident was observed sliding from a wheelchair because the seatbelt was not fastened, and the DON confirmed the CNA did not ensure the belt was secured. Another resident was found on the floor beside the bed after the head of bed had been elevated when it should have been flat due to the resident's seizure-related jerking movements, and the DON confirmed the bed position contributed to the fall. In a separate observation, one resident entered another resident's room while a CNA called out from the hall but did not go to redirect the resident, and the resident in the room called for help because of the unwanted person; the DON later stated the CNA should have gone to redirect the resident away from the room.
Missed Sacral Pressure Ulcer Assessment and Delayed Wound Care
Penalty
Summary
The facility failed to identify and provide treatment and services for a Stage Three sacral pressure ulcer for one resident who was admitted with osteomyelitis of the left foot requiring toe amputation, IV antibiotics through a PICC line, and AKI requiring hemodialysis. The resident was alert, oriented, and able to make needs known. On initial discussion, the resident reported that the dressing on their bottom had been missed over the weekend, stated the wound was present before admission, and described pain in the sacral area that became more intense when sitting. Hospital discharge paperwork documented a midline sacral Stage Three pressure injury with orders for cleansing, an enzymatic debriding agent, gauze, and a silicone dressing. Facility documentation later identified the wound as a facility-acquired unstageable pressure ulcer, and the DON acknowledged the admission LPN did not perform a thorough skin assessment and missed the sacral wound. The DON also stated that new resident skin assessments should include looking at every inch of skin and placing a wound consult with a treatment plan until consultation is completed. The admission LPN documented only amputated toes and a dialysis port on the comprehensive evaluation, and later said they had seen a small area on the coccyx but forgot to document it. The wound care specialist stated they were not formally consulted and only assessed the resident after the resident self-reported the wound while the specialist was on the unit for another resident. During a later dressing observation, the resident’s coccyx wound was found open with no dressing in place, and the resident stated no one had put the dressing back on after they had soiled it earlier that morning.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. During observation, interview, and record review, multiple residents reported delayed assistance with incontinence care, call light response, meals, and water, and several residents stated that staffing was especially poor at night and on weekends. Residents identified as needing help with toileting, transfers, feeding, and supervision described long waits for care, with some stating they were left wet in bed, did not receive timely assistance to eat, or did not receive fresh water for extended periods. On 4/6/26, R58 reported that call lights often took about an hour to be answered, especially at night and on weekends. R101 was observed crying and stated that the last time her incontinence brief had been changed was around 11:00 PM the previous night; she reported she had not yet been changed and said staff sometimes did not have enough help to take her to the toilet, causing her to wet her pants. R101 and her roommate were observed with Styrofoam cups dated 4/5/26, and both indicated water had been passed only that morning and not since. R55 reported being left wet in bed and said there had only been one person working on the hall the previous evening. R79 was observed with an empty water cup dated 4/5/26 and stated nobody had passed fresh water since Sunday morning. R17 stated that only CNAs changed him or got water because nurses were too busy, and that he needed help to eat but by the time staff assisted him, the food was cold and he did not want to eat it. Resident interviews on 4/7/26 with 11 anonymous residents further described staffing shortages. Four residents said there was not enough staff, one reported CNAs had been changed to 12-hour shifts and then quit from burnout, and another said a nurse did not come in on Easter Sunday so another nurse covered the whole C unit. Residents also reported wandering residents entering rooms and taking belongings, call lights not being answered, and incontinence care not being provided in a timely manner. Nine of 11 residents said they did not receive fresh water every day. Staff interviews and schedule review confirmed call-ins and short staffing on the 7 PM to 7 AM shift, with two CNAs covering the C and D halls and no nurse assigned to the D hall, and no nurse starting on the C hall until about 8:15 PM. The Administrator and DON confirmed several call-ins and that no nurse showed up for the evening shift.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain best practices in food service and hydration areas during an initial kitchen tour and related observations. In the upright cooler, an opened container of hummus with facility-marked use-by dates of 3/27-4/4 and an opened package of sliced cooked turkey breast with facility-marked use dates of 3/31-4/5 were observed; dietary staff member LL discarded both items when they were identified. The report cited 2022 FDA Food Code section 3-501.18 regarding ready-to-eat, time/temperature control for safety food that exceeds the specified time and temperature combination. During observation of two nursing hydration carts being prepared for use on the units, each cart had an attached mesh bag used to store the ice scoop. The storage bags were observed to be soiled and discolored on the bottom interior, not removable for routine cleaning, and uncovered so the ice scoop was exposed to potential contamination in the unit hallways; one bag was also frayed and torn. Later observations in the dining room found the ice machine bin drain line soiled with a black substance, and in the kitchen several ceiling tiles adjacent to the ceiling vent were soiled with dust buildup. The report cited FDA Food Code sections 4-202.16, 4-903.11, 6-501.18, and 6-501.12 related to nonfood-contact surfaces, storage of cleaned equipment, cleaning of plumbing fixtures, and cleaning of physical facilities.
Failure to Maintain Resident Dignity During Care and Meals
Penalty
Summary
The facility failed to ensure treatment in a dignified manner for seven residents during observations of care and meals. One CNA transported a resident to the shower room in a shower chair by pulling the chair forward while the resident faced rearward. During lunch in the dining room, staff were overheard talking across the room about residents’ physical abilities to feed themselves and repeatedly referring to some residents as “feeders,” and another CNA was overheard asking if a resident was a feeder. The Administrator later acknowledged that it was not appropriate to refer to residents as feeders. Additional observations showed a CNA providing one-to-one feeding assistance to a resident while scrolling through a cell phone between bites. Two residents were seated at an adjustable table that was in its lowest position and only reached their knees, and another resident was observed hunched over while self-feeding from a table at knee level. An LPN was observed standing over a resident while assisting with breakfast and continued to do so after stating there were no chairs in the room. In another hallway observation, an unknown staff member was talking on a cellular phone and then discussing personal business in the hallway while transporting a resident in a wheelchair.
Medication Administration, Diet Order Clarification, and Skin Assessment Failures
Penalty
Summary
The facility failed to provide medications according to professional standards of practice for two residents. On 4/6/26 at 9:42 AM, an LPN entered the room of two residents with both residents’ medications, gave one resident her medications first, and then gave the other resident’s medications. When interviewed later that day, the LPN stated that medications for different residents were not supposed to be prepared at the same time, but she was trying to get them done. The DON later confirmed that nurses should not prepare medications for different residents at the same time. One resident had diagnoses including hereditary spastic paraplegia and dementia with moderately impaired cognition, and the other had diagnoses including a history of stroke and diabetes with intact cognition. The facility also failed to ensure diet orders were clarified and accurate for a resident receiving tube feeding and pleasure feeding. The resident was observed receiving nutrition through a feeding tube, with orange juice present on the over-bed table, while the clinical record contained active orders for both NPO status for tube feeding and a regular pureed diet with thin liquids and 1:1 assistance for pleasure feeding. A meal tray labeled as a pleasure tray with 1:1 feed was later delivered, and orange juice was again observed in front of the resident. The NP note stated the resident had been NPO since returning from hospitalization and that the current feeding regimen would continue until SLP evaluation and further recommendations, while the SLP screen documented that the resident was cleared to return to the previous pleasure tray diet. The unit manager stated there should not be two conflicting orders and that they should have been clarified before food was served by mouth, and the DON stated the nurse should have contacted the dietician for clarification prior to serving food. The facility failed to assess skin under an undated dressing for a resident with bilateral forearm dressings. The resident was observed with an undated dressing on the right forearm and another on the left forearm, with bruising visible underneath the left dressing. The resident had diagnoses including peripheral vascular disease, heart disease, and dementia, and had moderately impaired cognition. No physician order for dressings was found in the record. When the DON later removed both dressings, she stated they appeared to be from a blood draw and explained that the last blood draw at the facility had been months earlier, while the resident had been readmitted from the hospital shortly before the observation. The DON stated her expectation was for the nurse to remove the dressing to see what was under it and assess the skin.
Failure to Assess and Treat Multiple Left Lower Leg Skin Openings
Penalty
Summary
The facility failed to identify, assess, implement treatment for, and follow physician’s orders related to a resident’s left lower leg skin tear and additional open areas. The resident had severe cognitive impairment, was dependent on staff for all activities of daily living, and had diagnoses including Alzheimer’s disease, protein-calorie malnutrition, unspecified convulsions, and anoxic brain damage. The resident also had a care plan noting risk for skin integrity related to vigorously kicking the left leg at times, with tubi grip ordered for both legs. On 3/30/26, staff documented a skin tear on the resident’s left shin, and hospice staff cleaned and covered the area with treatment orders placed. On 4/1/26, the resident was again noted to have a skin tear to the left shin and the area was cleansed and dressed. However, there was no documented assessment form for the skin tear or any other open areas, and no documentation of additional open areas despite later findings. The physician’s order included cleaning the left shin with normal saline, covering with border gauze, applying tubi grip to both legs, and removing tubi grip and checking skin integrity every shift. During observation on 4/6/26 and 4/7/26, the resident was seen repeatedly kicking the left leg up and down while seated in a geri-chair. Five pink open areas were first observed on the top of the left lower leg without a dressing, and later multiple open areas were found on the top and back of the left lower leg after a dressing was removed. Staff reported the wound was thought to be only a skin tear, one LPN stated she was not wound care certified, and the treatment nurse reported she had not looked at the resident’s left lower leg. The DON acknowledged the wound should have been assessed and that the physician’s orders should have been followed, while the facility record showed no documented wound assessment and no elastic bandages observed on the resident’s bilateral legs during the observations.
Failure to Provide Ordered Pain Relief and Antibiotics for Dental Infection
Penalty
Summary
The facility failed to ensure a resident with intact cognition and diagnoses including DiGeorge Syndrome, severe depressive disorder, and bacterial infection received needed pain management and antibiotic treatment for an infected tooth. The resident reported right lower tooth pain beginning on 3/3/26, and a provider note documented a suspected tooth abscess with an order for Augmentin. The medication administration record showed the antibiotic was not given as ordered on 3/3/26 and again on 3/10/26, resulting in the resident receiving only six days of the prescribed seven-day course. Dental services later evaluated the resident on 3/20/26 and documented dental pain in the lower right, decayed teeth, and a recommendation for extraction and a 10-day course of amoxicillin. The MAR showed the amoxicillin ordered on 3/20/26 was not administered on 3/20/26 or 3/21/26, with the medication noted as not available and on order. A progress note on 3/25/26 documented continued toothache and an order for Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed for 14 days. The resident continued to report severe pain, including 10/10 tooth pain on 4/6/26 and 4/7/26, and received ibuprofen. The record contained no notes showing the physician was contacted about the excessive pain. On 4/8/26, the resident again reported being in pain and stated the call light was out of reach; the resident also said staffing purposely did not place the light within reach. The DON acknowledged awareness of the tooth infection, missing antibiotic doses, and uncertainty about why the opioid order had been discontinued, but could not explain why the physician was not contacted regarding the resident’s high pain levels.
Failure to Provide Fresh Water Consistently
Penalty
Summary
The facility failed to ensure fresh water was passed and available to residents consistently and upon request for four residents reviewed for hydration: R4, R22, R79, and R101. On 4/6/26 at 9:30 AM, R101 and R22, who were roommates, were observed with Styrofoam cups dated 4/5/26 from 7:00 AM to 7:00 PM, and both stated that water had last been passed on the morning of 4/5/26 and had not been passed again by the time of the observation. On 4/6/26 at 10:04 AM, R79 was observed with a Styrofoam water cup dated 4/5/26 from 7:00 AM to 7:00 PM; when asked about fresh water, R79 shook the cup, which was empty, and said nobody had passed fresh water since Sunday morning 4/5/26. During an interview on 4/7/26 at 10:00 AM with 11 residents who wished to remain anonymous, 9 of 11 reported they did not receive fresh water every day. Residents described the problem as chronic, said they had gone a whole day without water, and reported that when they asked a CNA for water, the CNA assigned to their roommate would say they were not their CNA and would not get them water. One resident also reported not being given fresh water at night and said that when they asked, staff said they would bring it but never returned. Resident council minutes from October 2025 through March 2026 documented repeated concerns about not receiving fresh water every day. The DON stated that water was passed each 12-hour shift with no specific required time and that staff should provide water upon request or if cups were empty; the DON was not aware that water had not been passed on 4/5/26 after the first shift on A Hall. R101 had a history of stroke and diabetes and was cognitively intact; R79 had COPD and moderately impaired cognition. R4 was admitted with osteomyelitis of the left foot requiring toe amputation, IV antibiotics via PICC line, and AKI requiring hemodialysis, and was alert, oriented, and able to make needs known. R4 reported requesting a glass of water four to five times on Easter Sunday and not receiving anything to drink until the next day, despite knowing they needed to drink more because of urination concerns.
Resident Council Grievances Were Not Promptly Addressed
Penalty
Summary
The facility failed to promptly act on grievances raised through the resident council, and concerns documented in council minutes from October 2025 through March 2026 remained unresolved for multiple residents. The minutes reflected repeated complaints about not receiving fresh water every day, as well as concerns that CNAs were splitting rooms, using phones during care, and telling residents they would return but not coming back. During a confidential interview with 11 residents who attended resident council meetings, 9 reported ongoing concerns that had not been resolved, including lack of fresh water, staff not returning after answering call lights, and staff talking on phones or wearing earbuds while providing care. Residents described repeated problems with access to water and assistance. Several said they did not receive fresh water daily, including at night, and one resident reported going a whole day without water. Residents also reported difficulty obtaining water because of the split-room CNA assignment system, where a CNA would say the roommate was not their resident and would not provide water. One resident stated that when staff passed medications, there was sometimes no water available except a small cup brought by the nurse. Another resident reported that staff would say they would bring water or return after being asked, but often did not come back. Residents also reported other unresolved concerns affecting daily care and the environment. Four residents said there was not enough staff, with reports of CNAs and nurses covering multiple units, burnout from 12-hour shifts, and missed coverage on the evening of Easter Sunday. Three residents reported wandering residents entering rooms and taking belongings, and one resident reported delayed incontinence care, stating a brief changed at 11:30 PM on 4/5/26 was not changed again until a shower at 3:00 PM on 4/6/26. Multiple residents also reported dirty rooms and bathrooms, and one resident said housekeeping concerns brought to a department head were met with anger and were not resolved.
Medication Not Administered Per Order
Penalty
Summary
The facility failed to ensure medications were acquired and administered according to physician orders for one resident. The resident was admitted and later readmitted with diagnoses including peripheral vascular disease, heart disease, and dementia, and the MDS assessment indicated moderately impaired cognition. A physician order dated 4/2/26 directed Pregabalin 100 mg by mouth at bedtime for neuropathy, but the April MAR showed the resident did not receive the medication on 4/2/26, 4/3/26, 4/4/26, or 4/5/26. Medication Administration Notes documented that Pregabalin 100 mg was on order and waiting for the pharmacy to deliver on multiple days. During interview, the DON stated she had not known the resident had not received the medication, did not run medication audits, and relied on Unit Managers’ reports in morning meetings; she also stated there had not been a morning meeting since 4/2/26. The DON said nurses should have contacted the pharmacy and physician when the medication was not available. A review of the facility’s back-up medication supply showed six capsules of Pregabalin 100 mg were available, and the DON later stated the nurses should have used the back-up supply until the pharmacy delivered the medication.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that one resident's call light was within reach. On 4/6/26, the resident was observed sitting in a wheelchair with food on their shirt, reported being in pain, and stated they wanted to see a nurse, but the call light was out of reach and the nurse was informed of the resident's pain. On 4/8/26, the resident was again observed sitting in a wheelchair, reported pain in the lower left jaw area, and stated they needed assistance, but the call light was on the other side of the bed and the resident could not push it for help. The resident stated they believed staffing purposely did not put the light within reach. The resident's record showed diagnoses including DiGeorge Syndrome, severe depressive disorder, and bacterial infection, and the most recent MDS showed a BIMS score of 14/15. The DON was later informed of the call light being out of reach and stated staff should ensure call lights are in reach.
Unclean Resident Bathroom and Nonworking Clock
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two residents. One resident, who had sarcoidosis and moderately impaired decision-making ability, was observed in bed with a wall clock at the foot of the bed that remained stuck at 8:50 during multiple observations. The resident indicated that she could read the clock and that it was important to know the actual time, but the clock was not working. Another resident, who had COPD and moderately impaired cognition, reported that it took a long time for her room and bathroom to be cleaned and that she often had to make her own bed and clean the bathroom. She stated that the adjoining resident sometimes left soiled briefs with feces, urine, and menstrual blood on the floor, the toilet was often dirty, and the trash was not emptied regularly. Observation of her bathroom showed a urinal with dried brown substance caked on the bottom, a trash can filled to the top with soiled briefs with visible fecal matter, and a toilet with dried brown substance on the outside front part; the bathroom remained in the same condition on a later observation.
Failure to Release and Document Seatbelt Restraint Use
Penalty
Summary
The facility failed to release a seatbelt restraint during supervised activities and supervised dining, and failed to document removal of the restraint every two hours per the physician’s order for one resident, R60. R60 was observed in a wheelchair with a seatbelt fastened across the waist while in the resident’s room on 4/6/26, in the activity room during a scheduled music activity on 4/7/26, and in the dining room while eating lunch on 4/8/26. During the observations, staff were present in the activity room and dining room providing assistance to other residents, and the seatbelt remained fastened across R60’s waist. R60’s record showed diagnoses including diabetes, chronic kidney disease, dementia, depression, and anxiety disorder. The physician’s order dated 8/24/24 directed that the seatbelt restraint be released every 2 hours and with supervised activities, and the care plan directed release and repositioning every 2 hours, with supervised meals, supervised activities, and toileting. When the DON was interviewed on 4/7/26 about documentation for restraint release, the DON stated the facility did not have a place to document the release of restraints. The facility policy stated restraints should be periodically removed and should always be removed during supervised mealtimes and activities unless clinical contraindications are documented.
Failure to Provide Ordered 1:1 Feeding Assistance and Oral Hygiene
Penalty
Summary
The facility failed to assist one resident with activities of daily living, specifically oral hygiene and feeding assistance. On 4/6/26, the resident was observed lying in bed receiving nutrition through a feeding tube, with a cup of orange juice on the over-bed table and a copious amount of thick, stringy, white substance extending from the top to the bottom of the resident’s mouth. When asked, the resident stated staff did not often assist with brushing their teeth and said they wanted their mouth cleaned and teeth brushed. The resident’s record showed active orders for a regular diet with pureed texture, thin consistency, and 1:1 assistance at all meals for pleasure feeding, with a start date of 3/11/26. On 4/7/26, a CNA delivered a breakfast tray, placed the food in front of the resident, and left the room; the meal ticket noted pleasure tray 1:1 feed. The SLP documented that the resident had been cleared to return to the previous diet with 1:1 assist as needed for all meals, but the care plan was not updated to include this intervention and the Kardex did not include instructions for 1:1 feeding assistance. The resident’s care plan also identified oral/dental health problems and directed staff to provide, assist, and encourage oral hygiene, including set up and assistance with brushing. The DON stated the CNA should have stayed with the resident to provide feeding assistance and that oral care was performed in the morning, at night, or when visibly needed. The resident had diagnoses including sarcoidosis and dysphagia, and the MDS indicated moderately impaired cognition and dependence on staff for oral hygiene.
Failure to Assess and Discontinue Unneeded PICC Line
Penalty
Summary
The facility failed to assess and monitor the continued need for a PICC line used for IV antibiotic administration for a resident admitted with osteomyelitis of the left foot requiring toe amputation, acute kidney injury, and hemodialysis. The resident was alert, oriented, and able to make needs known. During an initial interaction, the resident reported concern about the PICC in the right upper arm, stating it had been placed for antibiotics, had not been used in a while, and the last attempt to flush it would not work. The resident also said the line was uncomfortable and becoming annoying. Observation of the PICC site showed the dressing dated 3/18, with rolled adhesive edges not fully adhered to the skin, a large amount of dark brown dried blood at the insertion site under the transparent dressing, and dried blood inside the catheter lumen. The resident also reported that the clear dressing would sometimes bubble and they had to press the air out. Record review showed orders to flush and monitor the PICC until 3/23 and to change the transparent dressing weekly, while the last antibiotic infusion was documented on 3/17. Nursing leadership acknowledged the PICC should have been assessed for discontinuation sooner than 4/6, and an LPN stated the order to discontinue the PICC was placed only after noticing the resident still had the line and realizing antibiotics had already ended.
CNA competency and training records were incomplete
Penalty
Summary
The facility failed to ensure that two CNAs had the appropriate competencies to care for residents, including new hire evaluations, yearly competency evaluations, and 1:1 training related to falls and transfers. One CNA was hired on or about 1/20/26, but the personnel file contained no documentation of initial training upon hire or 1:1 training related to R5's fall. Another CNA had been hired on 1/7/2025, and the last competency evaluation in the file was completed upon hire, with no yearly training or evaluation provided. The deficiency was identified during review of an incident involving R5, who was observed lying in bed with a sling on the left arm after reporting that a CNA turned them onto their side, placed a bedpan on the bed, and left the room while the resident was on their side. R5 rolled off the bed and was sent to the hospital, where they were diagnosed with a left shoulder fracture. RN MM reported hearing yelling, finding R5 on the floor, and stated that the CNA should never have left the resident alone because the resident was bedbound, obese, and had nothing to hold on to while on their side. The report also states that RN MM provided 1:1 training with the CNA after the incident, but the personnel file did not contain documentation of initial training or 1:1 training.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow its Enhanced Barrier Precautions (EBP) policy for one resident who was admitted with osteomyelitis of the left foot requiring toe amputation, IV antibiotics through a PICC line, acute kidney injury, and hemodialysis. The resident was alert, oriented, and able to make needs known. During a pressure ulcer dressing observation, there was no EBP signage or PPE outside the resident’s room, and an LPN donned only gloves while cleansing and treating an unstageable coccyx pressure ulcer with an open horizontal wound and yellow slough. When interviewed, the LPN stated they had been educated on EBP when hired but did not think the resident needed EBP because the resident did not have a Foley catheter and was not on antibiotics, though they said they could figure it out. The Infection Control RN stated that residents with pressure wounds requiring dressing changes do qualify for EBP and that the facility discusses EBP status in daily meetings, but did not know why this resident was not on EBP and acknowledged they should have been.
Incomplete Investigation of Alleged Mistreatment and Injury of Unknown Origin
Penalty
Summary
The facility failed to complete a thorough investigation of an alleged mistreatment and injury of unknown origin involving a resident who had diabetes managed with insulin, ESRD requiring hemodialysis, limited mobility, and use of a Hoyer lift. The resident’s spouse reported that the resident was verbally challenged by a CNA when the resident did not want to get up and get dressed, and that an improper Hoyer transfer caused skin tears to the neck and head. The resident’s MDS documented a BIMS score of 13/15, indicating no cognitive impairment. The clinical record showed that on the morning of the incident, a nurse overheard the resident yelling in the room and learned from the aide that the resident had said no to getting up and did not want to get out of bed until later, but the aide still proceeded with getting the resident dressed and placing the Hoyer pad underneath him. The nurse documented open areas on the left side of the body and that the resident requested the aide be removed from future care. Later interviews with nursing staff described arguing between the CNA and the resident, with the resident stating the CNA was not listening and did not want to get up. One nurse observed skin tears on the neck, arm, and another area, and believed they may have resulted from the Hoyer sling being pulled up from under the resident, but no staff member witnessed the injury. The investigation documentation did not address predisposing environmental, physiological, or situational factors. The DON’s late entry note stated the interdisciplinary team met to discuss skin tears and attributed the injury to the resident’s fragile skin and the Hoyer process, but the DON could not explain why only the neck was identified in one note when other injuries were documented elsewhere, could not describe the treatment provided, and acknowledged there was no formal discussion with the involved staff or resident as part of the investigation. The record also reflected that the incident was assumed to be caused by the Hoyer without a thorough determination of how the injuries occurred.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency (SA) for a hospice respite resident. The resident was admitted for a five-day hospice respite stay with diagnoses including unspecified dementia, chronic respiratory failure, and a history of falling. On admission, documentation showed pain 0/10 and skin findings limited to right ankle discoloration and slight redness to the front peri area. A subsequent skin check documented no skin issues. At discharge, however, staff identified discoloration to the upper left shoulder described as purplish/yellow. The DON assessed the area and noted it appeared to be from pre-trauma prior to admission, and an Incident/Accident (IA) report was completed. The IA report documented that the charge nurse discovered the discoloration during a pre-discharge skin assessment, that the DON observed purple and yellow coloration suggesting healing, and that the facility could not identify a fall or other cause for the bruise based on staff interviews. Further information from hospice staff indicated that hospice CNAs did not observe bruising on one visit but noted bruising to the left shoulder area on a later visit when providing a shower, and the facility was unable to determine the cause of the bruise. Imaging performed after discharge showed a healed or healing nondisplaced femoral neck fracture of the left hip, consistent with a non-acute fracture. The Administrator/Abuse Coordinator acknowledged in interview that the cause of the bruise could not be determined and stated they should have reported the injury of unknown origin to the SA. The facility’s Abuse Prohibition Policy required that allegations of abuse or neglect and incidents resulting in injury be thoroughly investigated, documented, and reported to appropriate state agencies, with notification to state or federal agencies within two hours if there was an abuse allegation or serious injury. Despite this policy and the unknown cause of the shoulder injury, the facility did not report the injury of unknown origin to the SA.
Resident's Right to Caregiver Choice Not Honored
Penalty
Summary
A resident reported having a conflict with a newly assigned Certified Nurse Aide (CNA), describing the CNA as having a bad attitude and being rude. The resident communicated their concerns to the Unit Manager and was assured that the CNA would no longer be assigned to their care. Despite this, staffing records and CNA charting documentation confirmed that the same CNA was assigned to the resident's care on at least two subsequent occasions, including after the initial complaint was made. The resident was unable to identify the CNA by name but recognized them by their behavior and reported the issue to the State Agency when the CNA was again assigned to their care. Interviews with facility staff, including the Unit Manager and Administrator, confirmed awareness of the resident's complaint and the expectation that the CNA should not have been assigned to the resident following the complaint. However, review of staffing sheets and care documentation showed that the CNA continued to be assigned to the resident's unit and provided care. The facility's own policy states that residents have the right to a dignified existence, self-determination, and freedom of choice regarding their care, which was not upheld in this instance.
Failure to Implement Grievance Process After Resident Complaint
Penalty
Summary
A resident reported having a conflict with a newly assigned Certified Nurse Aide (CNA), describing the CNA as having a bad attitude and being rude. The resident communicated their concerns to the Unit Manager and requested that the CNA no longer be assigned to their care. The Unit Manager confirmed receiving the complaint and assured the resident that the CNA would not be assigned to them again. However, the CNA was subsequently assigned to the resident's care on a later night shift. The resident was not assisted in filling out a grievance form, and no documentation of the complaint was found in the facility's records. Interviews with facility staff, including the Unit Manager and Administrator, confirmed that the grievance process was not followed as required by facility policy. The policy states that staff should encourage and assist residents in filing written grievances and that all concerns, whether oral or written, should be actively resolved. Despite this, the resident's complaint was neither documented nor formally addressed through the established grievance process.
Sanitation Deficiencies in Kitchen and Medication Cart
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during an inspection. In the walk-in cooler, there was pooled milk underneath milk crates, and a tray of raw chicken with blood pooled at the bottom and spilled on the floor. Raw ground beef and pork were stored directly next to the raw chicken, which is against the 2017 FDA Food Code that requires separation to prevent cross-contamination. Additionally, there were uncovered and unlabeled containers of white and tan powders next to the toaster, which should have been covered and labeled according to the FDA Food Code. Clean utensils were stored uncovered on a lower shelf, exposing them to potential contamination, contrary to the FDA guidelines that require such items to be stored in a clean, dry location and covered or inverted. The facility also failed to maintain the C hall medication cart water pitcher in a sanitary manner. A clear plastic pitcher filled with water and ice was observed on top of the cart with a sticker dated two days prior. Nurse 'E' admitted to forgetting to change the pitcher and stated there was no standard for when pitchers should be changed. Unit Manager 'F' indicated that water pitchers should be changed at the end of each night shift, with water and ice changed every shift, which was not followed. The facility's policy requires nursing staff to send water pitchers to the dietary department for daily cleaning and sanitizing, which was not adhered to in this instance.
Failure to Protect Residents' Personal Health Information
Penalty
Summary
The facility failed to protect the personal health information of nine residents, as observed during a survey. On two separate occasions, a bulletin board at the nursing station on the A unit displayed the names and dialysis treatment times of these residents, visible to anyone passing by. This was confirmed during an interview with the Director of Nursing, who acknowledged that the Unit Manager posted the schedules without ensuring they were covered to maintain privacy. The facility's HIPAA policy, dated September 30, 2021, emphasizes the residents' right to privacy and confidentiality of their personal and medical records, which was not upheld in this instance.
Inappropriate Use of Restraints for Two Residents
Penalty
Summary
The facility failed to ensure the appropriate use of restraints for two residents, R59 and R67, as observed during a survey. R59 was found in a Merry Walker, a device that should not be considered a restraint if the resident can exit it independently. However, R59, who has severe cognitive impairment due to dementia, was unable to demonstrate the ability to exit the device, indicating it functioned as a restraint. The Director of Nursing (DON) confirmed that R59 required staff assistance to get in and out of the Merry Walker, contradicting the facility's policy that it was not a restraint. R67 was observed with a seatbelt buckled across their lap while in a wheelchair, unable to unbuckle it themselves. Despite having a care plan that required the seatbelt to be released every two hours and during supervised activities, there was no evidence that this was being done. The DON acknowledged that the seatbelt should have been unbuckled during meals and activities, but there was no documentation to support that the restraint was being released as required. R67's care plan and physician's orders were not followed, as the seatbelt remained buckled during meals and while the resident was asleep, missing opportunities for supervised activities. The facility's policy on restraint management, revised in September 2022, states that restraints should only be used when medically necessary and must be removed periodically for repositioning and during meals and activities. The policy also requires a signed consent for the use of restraints, which was not documented for either resident. The facility's failure to adhere to its own policy and the lack of documentation for restraint release and consent contributed to the deficiency identified by the surveyors.
Failure to Develop Comprehensive Care Plan for Resident with Infections
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R111, who was observed with a midline intravenous (IV) line, antibiotics, and multiple infections. R111 was admitted with diagnoses including acute gastritis with bleeding, pneumonia, urinary tract infection (UTI), and cellulitis. Despite these conditions, the care plans did not address the resident's midline IV or the use of antibiotics for the current UTI and pneumonia diagnoses. The only care plan in place was for being at risk for a UTI, which had not been revised since the resident's admission. Interviews with the Infection Preventionist (IP 'A') and the Director of Nursing (DON) revealed a lack of clarity and responsibility regarding the initiation and revision of care plans. IP 'A' acknowledged the recent start of IV antibiotics for the resident's UTI and pneumonia but could not explain why the care plans were not updated. The DON indicated that IP 'A' should have initiated the care plans and acknowledged that any nurse could have done so. The facility's policy requires care plans to be specific, resident-centered, and updated with significant changes, which was not adhered to in this case.
Medication Administration Error Due to Inaccurate Communication
Penalty
Summary
The facility failed to ensure that care was provided according to professional nursing standards during a medication administration observation for one resident. Nurse 'J' was observed preparing medications for a resident at the medication cart but did not include Tylenol in the medication cup. When the resident questioned whether one of the pills was Tylenol, Nurse 'J' incorrectly informed the resident that a different pill was Tylenol, despite it not being present. This discrepancy was later confirmed by the Director of Nursing, who acknowledged that Nurse 'J' should not have misinformed the resident about the medication content. The facility's Charge Nurse Job description emphasizes the importance of providing safe and accurate medication-related interventions, including administering and documenting medications according to each resident's medication schedule using current standards of medication pass technique. The incident highlights a failure to adhere to these standards, as Nurse 'J' did not accurately communicate the contents of the medication cup to the resident.
Failure to Provide Scheduled Showers and Hygiene Care
Penalty
Summary
The facility failed to provide routine showers and hygiene care for two residents, R91 and R52, as per their scheduled care plans. R91, who has moderate cognitive impairment and is dependent on staff for bathing, reported not receiving a scheduled shower and confirmed it had been a while since their last one. The Electronic Medical Record (EMR) showed that R91 only received four showers in the past 30 days, with no documented refusals or alerts indicating refusal. The Director of Nursing (DON) confirmed the lack of documented showers and stated that any refusals should have been recorded in the TASK section, which did not occur. R52 was observed with poor hygiene, including greasy hair and face, discolored teeth, and debris in their nostrils, despite documentation indicating hygiene care was provided. R52, who has moderately impaired cognition and requires assistance for hygiene and bathing, reported receiving a bed bath two days prior. However, their appearance suggested inadequate care. The DON was informed of R52's condition but had not yet addressed the issue at the time of the report.
Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care treatments according to physician's orders for a resident with diabetic ulcers on both feet. On January 30, 2025, the resident was observed with dressings dated January 28, 2025, despite the requirement for daily changes. The resident confirmed that the wound care was not being performed daily as prescribed. A review of the treatment administration record showed that the treatment for January 29, 2025, was signed off as completed, even though the dressings had not been changed. The resident, who was admitted with chronic kidney disease, deep vein thrombosis, diabetes, and high blood pressure, had a wound care consultation on January 24, 2025, which specified daily treatment with Medi-honey and bulky dressings. The Director of Nursing acknowledged that treatments should be performed per physician's orders and only signed off if completed. The facility's policy on skin management, revised in August 2024, emphasizes the importance of providing appropriate treatment to promote prevention and healing for residents with wounds.
Failure to Prevent Accidents and Ensure Safe Transport
Penalty
Summary
The facility failed to implement necessary interventions and provide adequate care to prevent accidents for two residents, resulting in a fall and potential injuries. One resident, who had a history of falls, femur fracture, cataracts, anxiety, and dementia, was observed in a wheelchair without anti-tipping devices and without Dycem to stabilize the cushion. The resident's clinical record indicated the use of a seatbelt restraint, but an incident report revealed that the resident was found on the floor with the seatbelt improperly secured around their chest. The Director of Nursing confirmed that the seatbelt was not tightened correctly, allowing the resident to slide out of the wheelchair. Another resident was transported by a CNA in a shower chair facing rearward, with the CNA pulling the chair in a forward motion. This method of transport was identified as a safety concern by the Director of Nursing, as it was contrary to the facility's policy, which requires wheelchairs to be rolled in a forward direction. The CNA did not provide a satisfactory explanation for this method of transport, and the chair did not require maintenance or repair.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69% during a medication pass observation. Two medication errors were identified involving two residents. In the first instance, Nurse 'K' administered a 600 mg calcium supplement to a resident who did not have an order for it, instead having an active order for a Calcium Carbonate-Vitamin D 500 mg-200 mg combination supplement. This error was discovered upon reviewing the resident's medication orders. In the second instance, Nurse 'I' administered Dorzolamide eye drops to a resident, placing one drop in both the right and left eyes, contrary to the physician's order which specified administration in the left eye only. Nurse 'I' initially followed the instructions on the pharmacy label, which led to the error. The Director of Nursing acknowledged the errors and emphasized the importance of adhering to the Five Rights of medication administration. The facility's medication administration policy, revised in October 2023, requires verification of the medication label against the medication administration record for accuracy.
Failure to Obtain Physician-Ordered X-Rays for a Resident
Penalty
Summary
The facility failed to obtain physician-ordered x-rays for a resident, identified as R69, who was reviewed for radiology/diagnostic services. R69 had a physician order dated 12/28/24 for an x-ray of the right shoulder and hips due to pain. However, the record did not show any documentation that the x-rays had been obtained. R69 was admitted to the facility with diagnoses including type 2 diabetes, insomnia, and end-stage renal disease. An interview with the Director of Nursing (DON) revealed that for a STAT order, x-rays are usually completed within 4 to 6 hours, while general orders are set for three days to ensure they are not missed. Despite this protocol, the DON was unable to provide evidence that the x-ray ordered on 12/28/24 had been completed for R69.
Unsafe Doorway Frame Poses Risk to Residents
Penalty
Summary
The facility failed to maintain a safe environment for two residents, as observed in the room they occupied. The doorway frame had a sharp metal strip at ankle height that was pulled away, exposing sharp metal edges. This condition was observed on multiple occasions over three days, indicating a potential risk for injury to residents entering the room. The Unit Manager, who had been in their role for a short period, confirmed the hazardous condition upon being informed but was not previously aware of it. The facility's electronic reporting system, TELS, did not document this issue over the past three months. The Maintenance Director was also unaware of the problem until it was pointed out during the survey. Despite conducting environmental rounds, the maintenance staff had not identified the sharp metal doorframe as a concern. The facility's environmental audits for the past month did not specify which areas were observed, and no issues with the doorframe were documented. The facility's policy on environmental rounds emphasizes the importance of identifying and addressing issues to meet regulatory standards, yet this deficiency was not detected until the surveyor's intervention.
Failure to Ensure Resident's Right to Private Mail Delivery
Penalty
Summary
The facility failed to ensure a resident's right to receive unopened and private mail delivery, as evidenced by an incident involving a resident identified as R701. The resident, who was alert and had intact cognition with a BIMS score of 13/15, reported that a package containing pharmacy items was delivered to the facility but was opened and partially missing when it was finally brought to their room. The package, which included mouth wash and bed pads, was delayed by approximately a week, and upon receipt, the resident noted that three bottles of mouth wash and a pack of bed pads were missing. The facility's Administrator acknowledged that the package was mistakenly opened by staff and some items were missing by the time it was located. The facility's policy on resident mail clearly states that mail should be delivered unopened unless otherwise indicated by the resident or their representative, and staff should not open mail without permission. Despite this policy, the incident occurred, leading to a violation of the resident's rights to privacy and proper mail handling.
Failure to Notify Wound Care Practitioner and Update Interventions
Penalty
Summary
The facility failed to notify the appropriate wound care practitioner and update interventions for a resident with a pressure injury. The resident, identified as R704, was admitted with a stage IV pressure wound on the sacrum, initially identified as a skin injury upon admission from a hospital stay. Despite a treatment plan being put in place by the Director of Nursing (DON), there was no evidence of further interventions or notification to the wound care practitioner. The wound worsened over time, leading to the resident being sent to the hospital due to a change in condition. Interviews with staff revealed a lack of awareness and communication regarding the resident's wound care needs. The Unit Manager was unaware of the wound's history, and the Wound Care Coordinator noted that the wound had worsened after the resident's stroke. The DON acknowledged the lack of follow-up and was unaware that the care plan had not been updated since 2023. The facility was noted to be working on improving the consistency of their wound care program.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in one resident hitting another on the head. The incident occurred when a resident with severe cognitive impairment, who frequently wandered into other residents' rooms, entered the room of a cognitively intact resident. The latter resident, feeling threatened by the intrusion, responded by hitting the wandering resident on the head, causing redness. This incident was reported to the State Agency, and the facility conducted an investigation but could not substantiate abuse, although it was confirmed that the hitting occurred. The wandering resident, who has a history of adjustment disorder, insomnia, and dementia, was noted to have a BIMS score of 0/15, indicating severe cognitive impairment. This resident frequently wandered into other residents' rooms, which had been documented in their clinical record. Despite interventions such as placing stop signs in Russian and using a wander-guard, the resident continued to enter other rooms, leading to multiple incidents where other residents expressed discomfort or reacted aggressively. Staff interviews revealed that while they were aware of the wandering behavior and attempted to redirect the resident, they were not always successful in preventing the resident from entering other rooms. The facility's policy on abuse prohibition emphasizes the responsibility of staff to provide a safe environment, yet the interventions in place were insufficient to prevent the incident of physical abuse. The facility's failure to consistently monitor and redirect the wandering resident contributed to the deficiency in protecting residents from abuse.
Failure to Prevent Accidental Opioid Ingestion and Elopement
Penalty
Summary
The facility failed to protect a resident from a likely accidental opioid ingestion. A resident, who did not have any narcotic medications prescribed, was found unresponsive and required Narcan administration by EMS to become responsive. The resident's guardian expressed concern about the incident and lack of answers from the facility. The resident had severely impaired cognition and was independent for most activities of daily living. The facility's investigation revealed that the nurse assigned to the resident was also responsible for administering narcotic medications to another resident on a different unit, raising concerns about a possible medication error. The facility also failed to ensure timely interventions to prevent a resident with a known history of elopement and wandering from exiting the facility. The resident, who had severe cognitive impairment and a history of wandering and elopement attempts, managed to exit through a fire exit door. Although staff responded and redirected the resident back into the building, the incident highlighted the lack of adequate supervision and timely intervention. The resident's care plan included interventions such as stop signs in Russian and 30-minute checks, but there were no logins for time checks in the electronic task section. Interviews with staff and the administrator revealed awareness of the resident's wandering and elopement behaviors, but staff were not always present to redirect the resident. The social worker noted that while interventions were in place, staff were not always around to implement them effectively. Attempts to transfer the resident to a secured facility were not followed through by the resident's family, and there was no current guardian for the resident.
Failure to Conduct Ordered Urine Drug Test
Penalty
Summary
The facility failed to ensure a urine drug test was collected per physician orders for a resident who was reviewed for narcotic medications. A complaint was filed alleging that the resident, who does not take any narcotic medications, was found unresponsive and was administered Narcan by EMS, after which the resident became responsive. Despite the physician's order for a urine drug screen, the test was never conducted. The Assistant Director of Nursing (ADON) explained that the nurse was unable to collect the sample, and the order was automatically marked as completed when it reached the end date, even though the test was not performed. The resident, who was admitted with diagnoses including COPD, depression, and dementia, was found lethargic with slurred speech and pinpoint pupils, leading to the administration of Narcan. The attending physician indicated that these symptoms suggested the presence of an opioid, but confirmation would require a drug screen. The facility's policy requires that orders given by a physician or state-permitted healthcare professional must be accepted by a licensed nurse, yet the urine drug test was not collected, resulting in a failure to meet the resident's needs for timely and quality laboratory services.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,150 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Novi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Novi Lakes Health Campus | 1.9 mi | ★★★★★ | 0 | 0 |
| Fox Run Village | 3 mi | ★★★★★ | 0 | 0 |
| Northville Manor | 3.1 mi | ★★★★★ | 0 | 0 |
| Wellbridge Of Novi | 3.5 mi | ★★★★★ | 3 | 0 |
| Medilodge Of Farmington | 3.6 mi | ★★★★★ | 23 | 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.