Northville Manor

In the surveyor’s words

From the most serious findings on record at Northville Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 27, 2023

  This citation pertains to intake MI00135746. Based on interview and record review the facility failed to maintain a properly functioning alarm system for the northeast door of the facility for one cognitively impaired resident (R101) of three residents who were elopement risks. On 4/11/23, R101 left the facility without staff knowledge. The facility last saw R101 at 5:10 PM and identified R101 as missing at 7 PM during shift change. R101 was found wandering by the fire department. R101 was taken to the hospital and returned to the facility on [DATE] by relatives. This deficient practice resulted in the likelihood of serious injury, serious harm, serious impairment, or death when R101 left the facility unsupervised and without staff knowledge. […]

• Actual harm, isolatedF692Apr 26, 2022

  Based on observation, interview and record review, the facility failed to assess weight changes, nutritional interventions, and notify physician and resident representative of significant weight loss for two sampled residents (R2 and R10) of three residents reviewed for weight changes from a total sample of 14 resulting in significant weight loss and potential for further weight changes and compromised health conditions. Findings Include: Resident #2 In observations on 4/20/22 at 10:35 AM, 11:49 AM, 1:05 PM, 2:22 PM, 3:19 PM and 4:30 PM, R2 was observed ambulating in the hallways of the facility. In observations on 4/21/22 at 8:15 AM, 10:07 AM, 12:09 PM, 1:35 PM, and 3:49 PM, R2 was observed ambulating in the hallways of the facility. […]

• No harm, potential for more than minimal, widespreadF803Apr 17, 2025

  Based 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. Findings include: On 4/15/25 at approximately 10:35 a.m. posted in the dining room revealed the posted lunch menu listed: Braised Beef Tips, Parsley Noodles, Seasoned carrots, wheat rolls, Boston cream pie, coffee or tea, milk. However, during the lunch observation at 12:00 p.m. […]

• No harm, potential for more than minimal, widespreadF921Apr 17, 2025

  Based 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. Findings include: On 04/14/25 at 01:25 P.M., A common area environmental tour was conducted with Director of Maintenance I. The following items were noted: Resident Restroom [ROOM NUMBER]: The overhead clear plastic light lens cover was observed soiled with (dust, dirt, numerous dead insect carcasses). Director of Maintenance I indicated he would have staff clean and sanitize the light lens cover as soon as possible. […]

• No harm, potential for more than minimal, widespreadF727May 31, 2024

  Based 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. Findings include: On 5/30/2024 at 2:22 PM review of the staffing timecards with Scheduler B for the following dates revealed there was no consecutive 8 hour scheduled RN coverage: April 1st, 2nd, and 15th. (2024) May 12th, 14th and 26th. (2024) On 5/30/2024 at 2:25 P.M. the Director of Nursing (DON) was interviewed and said that he recently accepted the position as the DON and that there was another RN that worked midnights and weekends but went on an extended vacation. […]