The Manor of Novi

Inspectors wroteThis citation pertains to Intake 2588311. Based on observation, interview and record review, the facility failed to identify upon admission and provide treatment and services for a Stage Three pressure ulcer (having full-thickness skin loss, not involving underlying fibrous tissue) for one resident (R4) of four residents reviewed for pressure wounds resulting in a delay of treatment, pain and worsening of a sacral pressure wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent avoidable falls for three residents (R#'s 5, 60, and 50) of five residents reviewed for falls resulting in R5 sustaining a fracture to their left shoulder causing pain and hospital care, and provide supervision for wandering residents for two residents (R#'s 18 and 81) of two residents reviewed for supervision.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sufficient nurse staffing to meet the needs of multiple residents, including, but not limited to (R101, 55, 79, 44, 58, 17) and 11 anonymous residents that participated in the resident council meeting, resulting in the potential for delayed care for activities of daily living, medication administration and treatments to all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service and hydration areas resulting in the potential to spread foodborne illness to all residents. Findings Include:On 04/06/2026 at 8:55 AM during an initial kitchen tour observed in the upright cooler: 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. Dietary staff member 'LL' discarded upon observation. According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for seven residents (R#'s 45, 50, 21, 32, 8, 18, and 60) of seven residents reviewed for dignity, resulting in verbalized complaints from the anonymous group interview and the potential for embarrassment.

Inspectors wroteThis citation pertains to Intake Number: 2563496. Based on observation, interview, and record review, the facility failed to promptly act on grievances expressed by resident council members affecting nine of 11 residents who attended the confidential resident council interview, resulting in ongoing, unresolved concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services according to professional standards of practice related to administering medications for two (R22 and R101) of two residents observed; failed to ensure diet orders were clarified and accurate for one (R98) of two resident reviewed for tube feeding; and failed to assess skin under an undated dressing for one (R96) of two residents reviewed for non-pressure skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, implement treatment, and follow physician's orders for treatment and preventative care for one (R32) of two residents reviewed for non-pressure skin conditions, resulting in the development of 10 open areas to the resident's left lower leg and a delay in treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident received needed pain and antibiotic medication for an infected tooth for one (R8) out of two residents reviewed for dental/pain services resulting in continuous pain for over one month.

Inspectors wroteThis citation pertains to Intakes 2563496 and 2748674Based on interview and record review, the facility failed to ensure medications were acquired and administered per physician orders for one [R96] of four residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fresh water was passed and available to residents consistently and upon request for four (R4, R22, R79, R101) of four residents reviewed for hydration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents call light was within reach for one (R8) out of one resident reviewed for call light status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environment for two (R79 and R98) of four residents reviewed for the environment, resulting in R79 having to clean their own bathroom at times and R98 expressing frustration with a non-working clock.

Inspectors wroteBased on observation, interview, and record review, the facility failed to release a seatbelt restraint during supervised activities and supervised dining and document the removal of the restraint every two hours per the physician's order for one resident, (R60) of two residents reviewed for restraints.

Inspectors wroteThis citation pertains to Intake 2789175. Based on record review and interview, the facility failed to complete a thorough investigation of alleged mistreatment for one of one resident (R106) reviewed for injury of unknown origin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one (R98) of three residents reviewed for activities of daily with oral hygiene and feeding assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to adhere to professional standards of practice to assess and monitor the continued need for a PICC (Peripheral Inserted Central Catheter) for antibiotic administration for one (R4) of one reviewed for Intravenous (IV) therapy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two Certified Nursing Assistants (CNA NN and SS) out of five CNAs reviewed for competency evaluations received new hire evaluations, continuous yearly evaluations and 1:1 training regarding falls and transfers. This deficient practice had the potential to affect all residents at the facility, including R5.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and follow policies and procedures for Enhanced Barrier Precautions (EBP) for one (R4) of one reviewed for EBP.

Inspectors wroteThis citation pertains to Complaint #2729896Based on interview and record review, the facility failed to report an injury of unknown origin to the State Agency (SA) for one (R701) out of one resident reviewed for neglect/injury of unknown origin.

Inspectors wroteBased on interview and record review the facility failed to respect a resident's right to choices for one resident (R601) of three residents reviewed for resident rights resulting in verbalized complaints, frustration, and dissatisfaction with an assigned caregiver.

Inspectors wroteBased on interview and record review the facility failed to implement their grievance process for one resident (R601) of three residents reviewed for grievances, resulting in an undesired caregiver being assigned to the resident's care after they requested they no longer be assigned to their care.

Inspectors wroteWater Pitcher: On 1/30/25 9:20 AM observation of the C-hall medication cart had a clear plastic pitcher filled with water and ice stored on top of the cart. There was a sticker that had a handwritten date of 1/28. On 1/30/25 at 9:26 AM, Nurse 'E' was observed to return to the medication cart and confirmed they were assigned to the entire unit. When asked about the process for changing the water, ice, and plastic pitchers stored on the medication cart, Nurse 'E' reported they forgot to change the pitcher. When asked how often that gets changed, Nurse 'E' reported they would get a fresh pitcher every two to three days and further stated We don't have a standard of when we change our pitchers. Nurse 'E' was then observed to remove the existing sticker dated 1/28 and placed a new sticker dated 1/30. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect personal health information for nine residents (R#'s 89, 45, 266, 71, 73, 26, 38 and 42) of nine residents reviewed for personal privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate use of restraints, documented medical symptoms for the use of restraints, and consent for use for two residents (R#'s 59 and 67), of two residents reviewed for restraints.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan to address a resident's use of a midline intravenous (IV) line, use of antibiotics, and multiple infections for one (R111) of two residents reviewed for infection care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided per professional nursing standards for one resident, (R75) of five residents reviewed during the medication administration observation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure routine showers/baths and hygiene care were provided for two (R91 and R52) of five residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound care treatments were provided per physician's orders for one resident (R46) of one resident reviewed for non-pressure ulcer wound care, resulting in verbalized complaints and the potential for the worsening of wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions and provide care to prevent accidents for two residents, (R#'s 67 and 74) of three residents reviewed for accidents, resulting in a fall and the potential for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% when two medication errors were made for two residents (R#'s 57 and 75) of five residents reviewed during the medication pass observation, resulting in a medication error rate of 7.69%.

Inspectors wroteBased on interview, and record review, the facility failed to obtain physician ordered x-rays for one resident, (R69) of one resident reviewed for radiology/diagnostic services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a doorway frame was maintained in a safe manner for two (R36 and R54) of two residents reviewed for safe environment, resulting in the potential for injury (laceration).

Inspectors wroteThis citation pertains to Intake# MI00147133 Based on observation, interview and record review the facility failed to ensure the residents right to receive unopened and private mail delivery for one (R701) out of four residents reviewed for resident rights.

Inspectors wroteThis citation is pertains to intake MI00147430. Based on observations, interview, and record review the facility failed to notify appropriate discipline wound physician/practitioner and implement and update interventions for one (R704) resident of one resident reviewed for pressure injuries. Findings Include: On 11/12/24 at 9:30 AM, the Complainant was interviewed via phone called and stated that residents are not being turned every two hours as they should, because they are short staffed and are contracting bad wounds because of the lack support on the midnight shift. The Complainant was then asked could they provide a specific resident who had been affected by the lack of staffing and stated R704 is someone who had been affected. [...]

Inspectors wroteThis citation pertains to Intakes #MI00146313 and MI00146302 Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident resulting in R501 hitting R502 in the head out of four residents reviewed for abuse.

Inspectors wroteThis citation has two deficient practices. Deficient Practice #1-This citation pertains to Intake MI00146302 Based on observation, interview and record review, the facility failed to protect a likely accidental opioid ingestion for one (R503) of three residents reviewed for narcotic medications.

Inspectors wroteThis citation pertains to Intake MI00146302 Based on observation, interview and record review, the facility failed to ensure a urine drug test was collected per physician orders for one (R503) of three residents reviewed for narcotic medications.

Inspectors wroteThis citation has two deficient practices. DPS #1 This citation pertains to Intake #MI00140460. Based on observation, interview and record review the facility failed to ensure a resident with Type 1 diabetes was timely assessed for low blood sugar for one (R84) of three residents reviewed for change in condition/hospitalization resulting in R84's being found unconscious and hyperventilating with a blood sugar level of 34 causing a transfer to the emergency room and a six day stay at the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the dish machine for adequate sanitization, and failed to maintain the ice machines in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to maintain an antibiotic stewardship program and to ensure accurate monitoring and documentation of appropriate antibiotic use, with potential to affect all residents in the facility, and resulting in the potential for misuse of antibiotics and development of antibiotic resistance.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment timely for four (R8, R29, R49, R69 ) of 10 reviewed for timely assessments.

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment timely for six (R17, R40, R47, R57, R67, and R93) of 10 reviewed for timely assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to CMS (Center for Medicare and Medicaid) timely for ten (R8, R17, R29, R40, R47, R49, R57, R67, R69, and R93) of ten residents reviewed during the Resident Assessment review.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice: 1.) for four of four(4 of 4) medication rooms 2.) ensure medication refrigerator temperatures outside of acceptable parameters were addressed; 3.) ensure Hall A medication cart was secured and locked when unattended; 4.) ensure medications were not expired in D unit medication (med) storage room; and 5.) the freezers in the med room were maintained regularly without ice build-up, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increased potential for adverse effects, and resident, staff or visitor access to unsecured medication cart. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, (based on the reasonable person standard), the facility failed to ensure two residents (R49 and R59) of five residents reviewed for dignity, were treated in a dignified manner during dining.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Resident's personal preference for care was honored for one (R26) of one resident reviewed for self-determination/choices.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement effective pressure ulcer interventions for one Resident (R34) of three residents reviewed for pressure ulcers, resulting in the worsening of a facility-acquired pressure ulcer, infection, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure adequate monitoring of weights for one resident (R1) of four residents reviewed for nutrition/weight loss, resulting in the potential for continued unidentified weight loss and implementation of timely dietary interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and routinely change the dressing for a Peripherally Inserted Central Catheter (PICC-a long, thin tube inserted through a vein in the arm) for one resident (R106) of one resident reviewed for vascular access.

Inspectors wroteREFER TO INTAKE # MI00141500 Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when two (2) medication errors were observed from a total of 26 opportunities, affecting two (Resident #65 and Resident #562) of eight residents observed for medication administration, resulting in an error rate of 7.69%.

Inspectors wroteThis citation pertains to Intake Number(s): MI00135477. Based on observation, interview, and record review, the facility failed to operationalize their abuse policy to protect residents during an investigation of abuse for one (R804) of four residents reviewed for abuse and residents assigned to the alleged perpetrator.

Inspectors wroteThis citation pertains to Intake Number(s): MI00135477. Based on observation, interview, and record review, the facility failed to report an allegation of verbal abuse and misappropriation of property to the State Agency for one (R804) of four residents reviewed for abuse.

Inspectors wroteThis citation has two deficient practice statements (DPS). DPS #1 This citation pertains to intake number(s): MI00136651. Based on observation, interview, and record review, the facility failed to ensure there were physicians orders for a intrathecal baclofen pump (a device that delivers baclofen, a medication used to treat muscle spasms, directly into the spinal canal. It is surgically placed under the skin of the abdominal region of the body. Attached to the pump is a tiny catheter that extends into the spinal canal) that included instructions for maintenance and monitoring of the pump site for one (R803) of two residents reviewed for skin management.

Inspectors wroteThis citation pertains to Intake Number(s): MI00137760. Based on observation, interview, and record review, the facility failed to transfer two (R802 and R801) of three residents reviewed for accidents, in a safe manner, resulting in R802 falling in the shower.

Inspectors wroteThis citation pertains to intake number(s): MI00134971. Based on observation, interview, and record review, the facility failed to ensure there was a physician's order for oxygen, ensure application of a continuous positive airway pressure (CPAP) machine according to physician's orders, and ensure a physician ordered sleep study was completed for one (R805) of one resident reviewed for respiratory care.