Northville Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident and/or legal representative formulated an Advance Directive to grant and/or withhold life sustaining treatment (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) according to their wishes upon for two residents (6 and 25) of five residents reviewed for advance directives, potentially resulting in inaccurate life sustaining or life withholding medical treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms, affecting seven (2, 7, 10, 11, 12, 14, 15) of 15 resident rooms.

Inspectors wroteBased on observation, interview, and record review the facility failed to post revised menus and planned menus in advance for residents, resulting in the potential for a decline in nutritional status and resident dissatisfaction with meals. This deficient practice affected 27 of the 28 residents that consumed meals from the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 28 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies.

Inspectors wroteBased on observation, interview, and record review the facility failed to (1.) provide a dignified dining experience for three residents (R2, R3, and R7) of 25 residents observed during dining, resulting in staff standing over residents while assisting with feeding and (2.) meals served with an assortment of dinnerware, compromising the residents' rights to a respectful and individualized dining experience.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide behavioral health services for five residents (R6, R7, R8, R9 and R16) out of twelve residents reviewed for behavioral health resulting in the potential for residents not to attain or maintain their highest practicable mental and psychosocial well-being.

Inspectors wroteThis citation includes two Deficient Practice Statements. Deficienct Practice Statement #1: Based on observation, interview and record review, the facility failed to ensure proper cleaning and disposal of loose medications were conducted for one medication cart (North Hall Cart) reviewed for medication storage and cleanliness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure hygienic practices were performed while serving resident meals, resulting in the potential for food contamination. This deficient practice had the potential to effect 27 of the 28 residents that consumed food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of practice by ensuring medications were administered according to physicians' orders for three residents (R28, R2, and R21) of seven residents reviewed for medication administration, resulting in the potential for less than the therapeutic effect of the prescribed medication when medications were not taken as ordered.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (R21) out of five residents reviewed for immunizations were provided pneumococcal vaccination and education, resulting in the potential for development and spread of influenza among vulnerable residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide 80 square feet of space per bed within six (2, 7, 10, 11, 12, and 14) of 15 resident rooms, resulting in the increased likelihood for resident dissatisfaction with the amount of provided living space.

Inspectors wroteThis citation pertains to intake MI00149274. Based on observation, interview, and record review the facility failed to prevent physical restraint use for one resident (R401) out of 3 residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake MI00149272. Based on interview, and record review the facility failed to review/revise a care plan in a timely manner for one resident (R401) out of three residents reviewed for care planning.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs, affecting all 27 residents who resided in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products effecting 27 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, resident foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to effectively maintain continuity of internal programs throughout leadership changes, such as: reporting of abuse, Minimum Data Set (MDS) assessments, Quality Assurance and Improvement (QAPI/QAA) meetings, in-service, competencies/employee training, staffing, infection control, and vaccine policy affecting all 27 residents.

Inspectors wroteBased on interview and record review, the facility failed to consistently implement a comprehensive infection control program that conducted proper facility surveillance to readily identify trends of infections, resulting in missed opportunities for corrective actions and the potential for spread of infectious organisms throughout the facility affecting the entire census of 27 residents.

Inspectors wroteOn May 29, 2024 at 9:38 AM, the floor underneath Resident #128's (R128) tube feeding pole and at the head of R128's bed was soiled with debris, including torn paper, personal protective equipment (PPE) ties, fingernail clippings, a plethora of small unidentifiable particles, and clumps of hair. On May 30, 2024 at 8:07 AM, the floor underneath R128's tube feeding pole and at the head of R128's bed remained soiled with debris, including torn paper, personal protective equipment (PPE) ties, fingernail clippings, a plethora of small unidentifiable particles, and clumps of hair. On May 30, 2024 at 10:44 AM, Housekeeper C said she was responsible for processing the laundry, cleaning the common areas, and sweeping and mopping all of the residents' rooms but had not been able to do it all. Housekeeper C stated, I try to do it, because the residents should have a clean room. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were signed and submitted to CMS (Centers for Medicare and Medicaid Services) in a timely manner for six residents (R2, R12, R15, R20, R21, and R22), resulting in a delay in monitoring of the quality of care provided to the facility's residents and potential for delay in the identification of resident's health concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure certified nurse aides (CNAs) fulfilled the requirement to complete 12 hours of in-service education annually for four of five certified nurse aides (B, H, I, J) resulting in the potential for unmet resident care needs.

Inspectors wroteBased observation, interview, and record review, the facility failed to store biologicals and medications at the recommended temperature parameters for 12 residents (R2, R8, R9, R10, R11, R12, R13, R14, R16, R19, R23, and R24) and to consistently document the refrigerator temperatures for 27 residents reviewed for storage of drugs and biologicals.

Inspectors wroteBased on interview and record review, the facility failed to ensure consents for immunizations were obtained for three residents (R6, R8, and R10) and failed to ensure influenza and pneumococcal vaccines were offered for one resident (R18) out of five residents reviewed for immunizations, resulting in the potential for diminished ability to make informed decisions regarding plan of care and the spread of influenza and pneumonia among the 27 residents in the facility.

Inspectors wroteThis citation pertains to intake MI00143600. Based on interview and record review the facility failed to supervise residents to prevent a physical altercation for two residents (R16 and R26) of three residents reviewed for abuse, resulting in one resident receiving physical injuries.

Inspectors wroteThis citation pertains to intake MI00143600. Based on interview and record review the facility failed to report an incident of abuse to the State Agency in a timely manner for two residents (R16 and R26) of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper weight monitoring occurred for one resident (R128) deemed to be at nutrition risk out of three residents reviewed for nutrition status, resulting in the potential delay in identification of undesirable change in weight status and compromise in nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food preferences were honored for one resident (R129) out of three residents reviewed for food preferences, resulting in resident meal dissatisfaction.

Inspectors wroteBased on interview and record review the facility did not meet the requirement for an Infection Preventionist member of Quality Assurance and Performance Improvement (QAPI), Quality Assessment and Assurance (QAA) committee for three quarters, resulting in the potential for impaired resolution of infection control and prevention issues or decreased quality of care with the potential to affect all 27 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to provide 80 square feet of space per bed within 6 (2, 7, 10, 11, 12, 14) of 33 resident rooms, resulting in the increased likelihood for resident dissatisfaction with the amount of provided living space.

Inspectors wroteThis citation pertains to MI00140570. Based on observation, interview, and record review, the facility failed to consistently follow facility-wide planned menu and secure Registered Dietitian approval for menu change, resulting in a missed opportunity to ensure the nutritional adequacy of the substitution and serve expected meals to all residents consuming food from the kitchen.

Inspectors wroteThis citation pertains to MI00140570. Based on observation, interview, and record review, the facility failed to provide a homelike environment for one resident (R103) reviewed for homelike environment resulting in an unsanitary environment with a buildup of dried feces on two urinals sitting on the resident's overbed table and the resident's dissatisfaction with their living condition.

Inspectors wroteBased on interview and record review, the facility failed to perform and document neurological checks after a fall for one resident (R101) of three residents reviewed for injuries of unknown origin, resulting in the potential for head injuries to go unassessed and treated in a timely manner.

Inspectors wroteThis citation pertains to intake MI00139248. Based on interview and record review the facility failed to prevent misappropriation (theft of resident property) of resident narcotic medications, effecting seven residents (R2, R3, R4, R5, R6, R7, and R8) out of seven residents reviewed for diversion of medications, resulting in resident narcotic medications being stolen out of an unsupervised and unlocked nursing medication cart.

Inspectors wroteThis citation pertains to intake MI00139428. Based on interview and record review the facility failed to report an incident of misappropriation (theft of resident property) of resident narcotics to the state agency, effecting seven residents (R2, R3, R4, R5, R6, R7, and R8) out of seven residents reviewed for the diversion of medications, resulting in the potential for continued unreported incidents of misappropriation to the State Agency.

Inspectors wroteThis citation pertains to Intake MI00139311. Based on observation, interview, and record review, the facility failed to ensure qualified kitchen staff were available to manage and operate the kitchen properly, potentially affecting all residents eating meals from the kitchen, increasing the potential for cross-contamination and resident foodborne illness.

Inspectors wroteThis citation pertains to intake MI00139200 and MI00139311. Based on interview and record review the facility failed to administer medications in a timely manner for one (R104of three residents reviewed for late medication administration, resulting in the potential for unmet care needs.

Inspectors wroteThis citation has two deficient practices. This citations pertain to MI00139022. Deficient practice #1. Based on interview and record review, the facility failed to initiate blood sugar monitoring in a timely manner and consistently monitor blood sugars for one resident (R102) out of three residents diagnosed with diabetes reviewed for blood sugar monitoring, resulting in the potential for hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) to go undetected.

Inspectors wroteThis citation pertains to intake MI00138959. Based on interview and record review the facility failed to secure narcotic medication and failed to document the incident of missing narcotics, resulting in drug diversion and the potential for further incidents of missing narcotics.