The Manor of Farmington Hills

Inspectors wroteThis citation pertains to Intake Number 3055372. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal abuse and mistreatment by staff for two (R801 and R803) of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to Intake Number: 3055372. Based on interview and record review, the facility failed to report a witnessed incident of verbal abuse by staff to the State Agency and the Nurse Aide Registry, and report results of the investigation for one (R803) of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of residents, including R46 and R27, resulting in unmet care needs. This deficient practice had the ability to affect all residents that resided in the facility. On 9/23/25 at 10:16 AM, R46 was observed lying in bed. R46 was asked about care in the facility. R46 explained on 9/22/25 she had asked to be put back into bed around 5:00 PM, before dinner was served. was told they did not have enough staff as she required a mechanical lift and two staff members and had to wait until after dinner. was not assisted back to bed until 9:40 PM. was very tired from sitting in chair that long, and her bottom hurt. On 9/23/25 at 10:26 AM, R27 was observed lying in bed. R27 was asked about care in the facility. R27 explained she was not changed for 12 hours on 9/22/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in foodborne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' right to personal privacy during clinical assessment and provision of care for five (R14, R22, R31, R65, and R104) of five residents reviewed for privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, homelike environment, for 14 resident rooms (Room #s 101, 103, 106, 107, 110, 116, 118, 121, 237, 243, 244, 246, and 247) and throughout the hallways on Unit 1 and Unit 2.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of mistreatment to the Abuse Coordinator and/or the State Agency within the required time frame for one (R5) of two residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate diet orders were entered upon admission for one (R101) of one resident reviewed for tube feeding, who was not supposed to eat anything by mouth, resulting in the potential for aspiration when the resident consumed food by mouth.

Inspectors wroteThis citation has two deficient practice statements (DPS). DPS #1Based on observation interview and record review the facility failed to assess and treat a skin impairment in a timely manner for one (R99) of three residents reviewed for wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely identify and treat a facility acquired pressure ulcer for one (R10) of three residents reviewed for pressure ulcers resulting in R10 acquiring a Stage 4 (full-thickness skin and tissue loss) pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medication in a secure and safe manner and ensure proper disposal of medication for one of three medication carts observed for medication storage and labeling.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician ordered x-rays for one (R14) of one resident reviewed for radiology/diagnostic services.

Inspectors wroteThis citation pertains to Complaint #2649369Based on interview and record review the facility failed to provide 1:1 feeding assistance per the resident's assessment and plan of care and thoroughly conduct a Root Cause analysis investigation for one (R701) out of one resident reviewed for accidents/choking, resulting in R701 choking on corned beef and expired shortly thereafter.

Inspectors wroteThis citation pertains to intake #2573641Based on interview and record review the facility failed to timely assess, treat, notify the physician, and facilitate a transfer to the emergency room after an acute change of condition for one resident (R905), of three residents reviewed for change of condition, resulting in a transfer to the emergency room with a diagnosis of a heart attack requiring surgical intervention.

Inspectors wroteThis citation pertains to intake #2573641 and #1249526Based on interview and record review, the facility failed to ensure timely admission orders and assessments were completed for two residents (R#'s 902 and 905), of three residents reviewed for admissions, resulting in complaints of missed medications.

Inspectors wroteThis citation pertains to intake #1249414Based on observation, interview and record review, the facility failed to ensure a call system was operational for one resident (R901) of three residents reviewed for call systems.

Inspectors wroteThis citation pertains to Intake MI00153376 Based on observation, interview and record review the facility failed to protect Protected Health Information (PHI) for all residents residing on the 300 Hall on May 24, 2025, resulting in the potential for unauthorized disclosure without consent of resident protected health information.

Inspectors wroteThis citation pertains to intake# MI00152482 Based on observation, interview and record review, the facility failed to prevent new wounds from developing, provide wound care and complete/accurately document new skin impairments for two residents (R302 and R303) of three residents reviewed for wounds, resulting in R303's wound care not being completed per Physician's orders and R302's wounds including their right lateral hip, right heel, right toe, right lateral ankle and right lateral foot not being identified and treated in a timely manner.

Inspectors wroteThis citation pertains to Intake# MI00150024 Based on observation, interview and record review the facility failed to ensure a resident was turned properly per their needs to prevent accidents and ensure they were fully assessed following the accident for one (R702) of three residents reviewed for falls/accidents.

Inspectors wroteR902 Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to provide adequate and appropriate care to prevent a pressure wound for R902. A review of the medical record revealed R902 was readmitted to the facility on [DATE] with diagnoses that included: end stage renal disease and dependence on renal dialysis. On 1/14/25 at 10:55 AM, R902 was observed sitting up in bed eating breakfast. A brief interview was conducted with R902 at that time. At 11:17 AM, an observation of R902's buttocks was conducted with the assistance of Unit Nurse Manager (UNM) A. A pink wound dressing, no date noted was observed on the right side of R902's buttocks. On the left side was an identified open area with maceration. There was no treatment applied to the left buttocks. UNM A confirmed the left side opening and stated treatment should be applied to that area. [...]

Inspectors wroteThis citation pertains to intake: MI00149193. Based on observation, interview and record review the facility failed to accurately obtain and monitor weights for one (R902) of one resident reviewed for weight loss.

Inspectors wroteThis citation pertains to intake: MI00149193. Based on observation, interview and record review the facility failed to ensure the assessment and monitoring of an Intravenous (IV) catheter and Permacath site, for one (R902) of one resident reviewed for wounds.

Inspectors wroteThis citation pertains to intake MI00147820. Based on observation, interview and record review, the facility failed to provide appropriate treatment and interdisciplinary collaboration to prevent further decrease in range of motion for one resident (R902) of two reviewed for range of motion.

Inspectors wroteThis citation pertains to intake #MI00147667. Based on interview and record review the facility failed to ensure Physician orders were transcribed and implemented for bowel movements for one resident (R903) of of two residents reviewed for bowel and bladder.

Inspectors wroteThis citation pertains to intake: MI00146970. Based on interview and record review, the facility failed to continuously ensure orders were implemented for supplemental oxygen and for a CPAP (continuous positive airway pressure) machine, failed to implement care plans for chronic hypoxic and hypercapnic respiratory failure, failed to implement interventions for supplemental oxygen and the use of a CPAP machine, failed to provide the correct settings for the non-invasive ventilation as ordered by the Pulmonologist, failed to administer antibiotics as prescribed, and failed to provide the necessary CPAP/BiPAP (bilevel positive airway pressure) ventilation as needed for one R707 of two residents reviewed for falls, resulting in multiple incidents of respiratory distress and a change of condition that resulted in a fall, an acute corner fracture of the C5 vertebral body anteriorly and [...]

Inspectors wroteThis citation pertains to intake # MI00145991. Based on interview and record review the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were provided and completed for four (R169, R27, R42, and R62) of four residents reviewed for beneficiary notification, resulting in complaints of not being informed timely of private pay charges for continued services at the facility, and the inability to file an appeal.

Inspectors wroteR41 On 8/19/24 at 11:12 AM, the resident was observed laying in bed with supplemental oxygen via nasal cannula from an oxygen concentrator. When asked if they had any concerns with lack of sufficient nursing staff, R41 reported concerns with not having enough at times and having to wait long periods of time before staff will respond to their needs. They further reported it seemed like staffing was worse on the weekends. R42 On 8/19/24 at 11:38 AM, the resident was interviewed at bedside. When asked if they felt there was sufficient staffing to meet their needs, R42 reported they need to hire more people all around and couldn't get their pain pill this morning. They further reported at times they waited for help longer than 30 minutes. R77 On 8/19/24 at 12:50 PM, the resident was observed seated on the side of their bed. [...]

Inspectors wroteThis citation has two deficient practice statements (DPS). DPS#1 Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified manner for one (R34) of one resident reviewed for dignity, and multiple residents observed during dining.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs and preferences (including bed length and water in reach) for four (R34, R76, R89, and R170) of eight residents reviewed for accommodation of needs, resulting in residents complaining of being uncomfortable, frustrated over loss of independence with grooming or being able to get out of bed, and residents unable to hydrate with or without staff assistance.

Inspectors wroteBased on observation, interview and record review the facility failed to secure resident health information from being displayed in a manner viewable to anyone that passed by the nursing station for five (R119, R120, R121, R122, and R123) of five residents reviewed for privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician order for use of supplemental oxygen was obtained, including monitoring of the resident's respiratory status and maintaining the humidifier secured to the oxygen concentrator for one (R42) of one resident reviewed for respiratory care.

Inspectors wroteBased on interview and record review the facility failed to provide ensure consistent dialysis communication documentation and assessments were completed for two residents (R94 and R270), and failed to provide meals prior to hemodialysis appointment for one (R269) of three residents reviewed for dialysis. Findings Include: R94 R94 was long-term resident of the facility. R94 was originally admitted to the facility on [DATE]. R94's admitting diagnoses included end stage renal disease, atrial fibrillation, and diabetes. Based on the Minimum Data Set (MDS) assessment dated [DATE], R94 had a Brief Interview for Mental Status (BIMS) score 15/15 indicative of intact cognition. Review of R94's Electronic Medical Record (EMR) revealed that R94 was scheduled for hemodialysis 3 days per week since they were admitted to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, store, and discard expired medications and biologicals in four of seven medication carts reviewed, resulting in the potential for misuse and decreased efficacy of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menu items listed on meal tickets were provided for seven residents (R#'s 12, 101, 64, 34, 89, 59, and 100) of 28 residents reviewed for dining resulting in the potential for disappointment with meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fresh water and assistance with consuming fluids for four residents (R#'s 59, 34, 89, and 100) of four residents reviewed for hydration, resulting in the potential for dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner and in accordance with the scheduled mealtimes for the residents (including R39), resulting in late meals and resident dissatisfaction.

Inspectors wroteBased on observation, interview and record review, the facility failed to utilize appropriate infection control standards and practices including adherence to implementation of and donning proper Personal Protective Equipment (PPE) specific to Enhanced Barrier Precautions (EBP) (R172), proper hand hygiene, and unsafe disposing of human waste (R15), resulting in the potential for spread of infection that could potentially affect all residents in the facility. On 8/21/24 at 7:46 AM, Licensed Practical Nurse (LPN X) was observed during medication administration not performing hand hygiene. LPN X donned gloves to administer eye drops, and when the residents telephone fell to the ground, LPN X picked the phone up off the floor, hands remained gloved, placed the phone back to the resident, and attempted to administer eye drops without changing gloves and performing hand hygiene. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure all corridor areas used by residents were provided with safe and secure hand rails. This deficient practice has the potential to affect all residents who are independently ambulatory with, or without an assistive device.

Inspectors wroteBased on interview and record review, the facility failed to address grievances for one resident (R31), of one resident reviewed for grievances, resulting in unresolved concerns.

Inspectors wroteThis citation pertains to intake #MI00145754 Based on observation, interview, and record review, the facility failed to provide necessary care and services consistent with the residents needs and choices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meal set-up and one-to-one feeding assistance for one resident (R89) of four residents reviewed for activities of daily living.

Inspectors wroteThis citation pertains to intake #MI00145754. Based on observation, interview, and record review, the facility failed to provide consistent monitoring and assessment of changes in skin, and implementation of pressure-relieving interventions for two (R47 and R96) of five residents reviewed for pressure ulcer management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessment, monitoring, and provision of supplies for two residents (R#'s 31 and 15) who used urinary catheters, of two residents reviewed for urinary catheters, resulting in the potential for the development of urinary tract infections.

Inspectors wroteBased on observation, interview and record review facility failed consistently monitor weights for one (R29) of two residents reviewed for nutrition resulting in the potential for undetected weight loss, and overall decline in functional status.

Inspectors wroteBased on interview and record review, the facility failed to order laboratory tests timely for one resident (R31) who experienced signs and symptoms of a Urinary Tract Infection (UTI) and obtain physician ordered routine labs for one (R87) of two residents reviewed for laboratory service.

Inspectors wroteBased on interview and record review the facility failed to obtain and/or coordinate radiology services for an MRI (Magnetic Resonance Imaging) for one (R42) of one resident reviewed for radiology/other diagnostic services, resulting in verbalized concerns of the delay in obtaining the MRI, and the potential for delayed identification of any abnormalities which may require additional medical/treatment intervention.

Inspectors wroteThis citation pertains to intake: MI00145663. Based on observations, interviews and record reviews the facility failed to ensure sufficient staffing was provided to ensure adequate care was provided for two (R's 303 & 304) of three residents reviewed for Activities of Daily Living (ADLs) and Staffing. This deficient practice had the ability to affect multiple residents that resided in the facility.

Inspectors wroteThis citation pertains to intake #'s MI00138702 and MI00144605. Based on observations, interviews and record review, the facility failed to protect the Resident's (R611) right to be free from neglect, including the provision of medical assistance, activities of daily living (ADL) assistance, medication administration and nursing supervision/monitoring for one of three reviewed for neglect, resulting in the resident to have been abandoned at a chemotherapy appointment, waiting approximately five hours for family to pick them up and having to pay for an overnight motel room until the resident was able to go to the hospital for medical care.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six staff members reviewed for criminal background checks were screened for eligibility to work in a nursing home, resulting in the potential for abuse or neglect to occur. This has the potential to affect all residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's guardian of changes of condition for one (R702) of two residents reviewed for notification of changes.

Inspectors wroteThis citation pertains to intake #MI00143505 Based on interview and record review, the facility failed to document and address resident grievances for one resident (R705) of one residents reviewed for grievance resolution, resulting in verbalized complaints and frustration.

Inspectors wroteThis citation pertains to Intake #MI00142508 and Intake #MI00142954 Based on interview and record review, the facility failed to accurately complete assessments for one resident (R703) of three reviewed for change in condition resulting in R703 developing intense pain from a blood clot requiring hospitalization.

Inspectors wroteThis citation pertains to intake #: MI00142528 Based on interview and record review facility failed to implement and revise care plan interventions timely for one (R901) of three residents reviewed for care plan, resulting in development of two stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcers, undeteced weight loss, and admission to hospital for surgical debridement of the wound and PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube placement.

Inspectors wroteThis citation Pertain to Intake#: MI00142528 Based on record review and interviews facility failed to timely identify and address the nutritional needs; and monitor weights for one (R901) of three high risk residents reviewed for nutrition and weight loss. This deficient practice resulted in, undetected weight loss, further decline in nutritional status, developed two stage three pressure ulcers during their stay at the facility and transferred to hospital for PEG (Percutaneous Endoscopic Gastrostomy tube - a tube directly placed on stomach to provide nutrition and hydration) tube placement and surgical debridement of the wound.

Inspectors wroteThis citation pertains to intake#: MI00142528 Based on interview and record review, the facility failed to ensure the timely completion and submission of a comprehensive assessment after significant change in status for one resident (R901) of one reviewed for resident assessments, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review facility failed to assist with repositioning/off-loading to relieve prolonged pressure for two (R906 and R907) of two Residents, with multiple pressure ulcers, who were dependent upon staff for turning/repositioning, during multiple observations. This deficient practice has the potential to result in worsening of pressure ulcers with decline in overall health condition and hospitalization. R906 R906 is a long-term resident of the facility. R906 was originally admitted to the facility on [DATE] and had recent hospitalization and they were readmitted back to the facility on 1/9/24. R906's admitting diagnoses included multiple sclerosis, decubitus ulcers (pressure sores), and paraplegia (paralysis of both legs). [...]

Inspectors wroteThis citation Pertain to Intake#: MI00142528 Based on interview and record review, the facility failed to: 1) implement appropriate action to correct quality deficiencies; and 2) sustain a system to ensure corrective measures related to prevention and treatment of pressure ulcers/injuries for two (R906 and R907) of three residents reviewed.

Inspectors wroteThis citation pertains to Intake(s): MI00141146 This citation has two deficient practice statements (DPS). DPS #1 Based on interview and record review, the facility failed to assess and treat a surgical wound according to physicians orders for one (R705) of one resident reviewed for non-pressure wounds, resulting in a hospital transfer when R705's foot was observed to be swollen, warm, with surgical hardware embedded into the skin.

Inspectors wroteThis citation pertains to Intake Number(s): MI00140078, MI00140084, and MI00141881 Based on observation, interview, and record review, the facility to assess newly developed facility acquired pressure ulcers in a timely manner, perform accurate and timely ongoing assessments of wounds and perform treatments per physician's orders for two residents (R#'s R703 and 706) of four residents reviewed for pressure ulcers, resulting in the worsening of a stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcer to a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle. [...]

Inspectors wroteThis citation pertains to intake #MI00139090 Based on interview and record review, the facility failed to protect the resident's (R701) right to be free from physical abuse by Certified Nurse Aide 'C'. On 1/17/24 at 11:00 AM, a review of a facility reported incident investigation file provided by the facility was conducted. The file contained a typed document that summarized the incident and read, .On 6.21.23 the administrator was made aware of an incident involving (R701) and staff member (CNA, Certified Nurse Aide 'C'). The staff member allegedly struck (R701) in the face .The administrator interviewed the assigned staff member (CNA 'C') regarding this alleged allegation .When asked if she hand <sic> touched the resident in her face, or near her face in anyway <sic>? She replied 'no'. [...]

Inspectors wroteThis citation pertains to Intake Number(s): MI00141886 and MI00141946 Based on interview and record review, the facility failed to implement interventions to prevent falls in a timely manner for one (R707) of one resident reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to label and date food in the walk in cooler and freezer and failing to discard expired food items timely and 2. Failing to discard kitchen refuse in appropriate trash/refuse receptacles. These deficient practices have the potential to result in food borne illness among any or all the 98 residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate infection control measures were in place to 1) ensure proper disposal of soiled Personal Protection Equipment (PPE) for two (R239 and R241) and 2) proper hand hygiene was performed after removal of soiled PPE for residents (R241) who were observed for transmission-based precautions. These deficient practices have the potential for spread of infections to all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to complete a self-administration of medication assessment for one (R241) of one resident reviewed for the self-administration of medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure choices was provided for two (R's 240 & 37) of three residents reviewed for choices.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and comfortable home like environment for one of one resident (R3) resulting in the potential for resident dissatisfaction with their living conditions.

Inspectors wroteBased on interview and record review the facility failed to ensure regular care planning review conferences were held with the legally authorized resident representative for one resident (R64) of one residents reviewed for Comprehensive Care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and appropriate assistance with Activities of Daily Living (ADL) grooming, feeding assistance and showers for two (R36 and R54) of three Residents reviewed for ADL care resulting in the potential for negative physical, psychosocial outcomes, and potential loss of dignity for residents who are dependent on staff for assistance.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure wound care was completed per Physician's orders for one resident (R56) of three residents reviewed for wound care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate catheter care, monitoring and documentation was completed for three residents (R56, R80 and R190) of three residents who were reviewed for catheter care/Urinary tract infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure adequate monitoring of weights for one resident with weight loss (R64) of six residents reviewed for Nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral feeding (nutrition delivered from a surgically placed tube in the stomach) was provided according to physicians orders for one (R80) of three residents reviewed for enteral feeding and one (R15) additional resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to provide care and services to the residents. This had the ability to affect all residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure expired medications, Pneumococcal vaccines and a TB solution was removed from the facility's medication rooms and discarded for two of three medications storage rooms reviewed and failed to ensure a treatment cart was secured/locked of three carts reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate documentation in the residents' medical records for one (R56) resident.