Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Fox Run Village during CMS and state inspections, most recent first.
The facility failed to implement proper infection control practices during an influenza outbreak, with staff not adhering to PPE protocols and inadequate signage on resident doors. Observations showed staff entering rooms without proper PPE, and essential equipment like N95 masks were not readily available. The infection control program was under scrutiny, with discrepancies noted between staff training and actual practices.
A resident was found with unsupervised medications, and a nurse failed to follow pharmacy instructions for administering a B-12 tablet sublingually. The resident, with diagnoses including CHF and polyneuropathy, required assistance with daily activities. The ADON confirmed the nursing staff's responsibility to ensure proper medication administration.
A resident with severe cognitive impairment and mobility issues did not consistently receive assistance with oral hygiene, as required. The resident reported not receiving help with brushing their teeth, and observations confirmed this lack of care. The care assistant admitted to not providing oral care due to being busy, and facility documentation was inconsistent, with several shifts left blank. The facility lacked a specific care plan for the resident's oral hygiene needs.
A newly admitted resident did not receive several prescribed medications the day after admission due to the facility's failure to ensure medication availability. The ADON indicated that the admitting nurse should have arranged for a STAT delivery or checked the backup box, but no further information was provided on the issue.
A facility failed to ensure physician orders were in place for a resident with a suprapubic catheter. The resident was observed with unsecured catheter tubing dragging on the floor, and their medical record lacked active orders for catheter care. Nurse E confirmed the absence of orders, and the ADON acknowledged the oversight, noting that orders should be entered during the initial evaluation. No further corrective action was provided by the end of the survey.
A resident with influenza and a surgical wound did not have appropriate infection control measures in place, including missing or incomplete PPE supplies, lack of clear precaution signage, and delayed care planning. Staff and visitors were not provided with adequate information or resources to follow EBP and droplet precautions, and facility leadership confirmed these practices did not meet policy or training standards.
Surveyors found that several stairwell exit doors equipped with 15-second delayed egress locking systems did not have the required signage instructing individuals to push until the alarm sounds and the door can be opened. This deficiency was confirmed by facility maintenance leadership and could impact all residents during an emergency evacuation.
The facility did not ensure its automatic sprinkler system was maintained and tested as required by NFPA 25, with a sprinkler riser gauge last dated in 2019 and missing documentation for the 5-year check valve and internal pipe tests. The Maintenance Director confirmed these tests were not completed or documented at the time of survey.
The facility did not repair or locate fire dampers in its HVAC system as documented in a previous duct cleaning report, with the issue confirmed by maintenance leadership. This deficiency could impact all residents in the event of a fire.
Surveyors found that the facility did not maintain written records of monthly firefighter's service tests for elevators, as required by safety codes. The Maintenance Director was unaware of the requirement, and no documentation was available during the survey, potentially affecting all residents in an emergency.
The facility did not conduct fire drills at unexpected times as required, with drills on the first shift consistently held in the early afternoon and those on the third shift in the early morning. This deficiency was confirmed by facility leadership during record review and interviews, potentially affecting all residents in the event of a fire emergency.
Surveyors found that the facility did not have documentation for the required annual generator diesel fuel analysis, as confirmed by the Maintenance Director during record review. This deficiency affects compliance with NFPA standards for emergency power systems and could impact all residents in the event of an emergency.
Nine oxygen concentrators were observed stored less than five feet from oxygen cylinders in the Oxygen Room, failing to meet NFPA 99 requirements for separation of combustibles. This deficiency was confirmed by facility maintenance leadership and could affect six occupants in the event of a fire.
Inadequate Infection Control Practices During Influenza Outbreak
Penalty
Summary
The facility failed to ensure appropriate infection control practices during an influenza outbreak, particularly for residents on droplet precautions and those requiring Enhanced Barrier Precautions (EBP). Observations revealed that signage on resident doors did not specify the type of precautions or the specific personal protective equipment (PPE) required. For instance, R93's door lacked clear precautionary signage, and staff were observed not adhering to proper PPE protocols, such as wearing only a KN95 mask without additional protective gear when entering the room. Staff interviews highlighted a lack of clarity and adherence to infection control protocols. Care Assistant 'D' admitted to not donning the required PPE when entering R93's room and acknowledged the absence of N95 masks in the PPE cart. Nurse 'E' confirmed that N95 masks were stored at the nursing station, which was not communicated to visitors or staff. Additionally, Nurse 'E' was observed moving a nursing pushcart between rooms without sanitizing it, further risking cross-contamination. The facility's infection control program was under scrutiny, with the Assistant Director of Nursing (ADON) acknowledging the discrepancies between staff training and observed practices. The ADON and Director of Nursing (DON) confirmed that the observed practices did not align with the facility's infection control training. The lack of specific signage and accessible PPE, combined with inadequate staff adherence to protocols, contributed to the deficiency in infection control practices.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that nursing standards of practice were followed for medication administration for a resident identified as R5. During an observation, R5 was found in their room with eye drops and a medication cup containing three white pills, without a nurse present to supervise. R5 reported that a nurse had given them the pills and left the room without ensuring they were taken. R5 was then observed taking the pills unsupervised. Additionally, during a medication administration observation, Nurse E administered a Cyancobalamin (vitamin B-12) tablet along with other medications in a cup, contrary to pharmacy instructions that specified the tablet should be administered sublingually. R5's medical record indicated they were last admitted to the facility with diagnoses including congestive heart failure and polyneuropathy, and required assistance with activities of daily living. A physician order allowed for the self-administration of eye drops but did not include any other medications for self-administration. The Assistant Director of Nursing acknowledged that it was the nursing staff's responsibility to follow the rights of medication administration, including clarifying pharmacy instructions and ensuring residents ingest all medications under supervision.
Inconsistent Oral Hygiene Assistance for Resident
Penalty
Summary
The facility failed to consistently provide assistance with oral hygiene for a resident, identified as R34, who was unable to perform this activity independently. On multiple occasions, R34 reported not receiving assistance with brushing their teeth, despite being dependent on staff for such care due to their inability to get out of bed without a mechanical lift and two-person assistance. Observations confirmed that R34 had not received oral care by midday, and the care assistant assigned to them admitted to not providing this care due to being busy with other residents. The facility's documentation for oral care was inconsistent, with several shifts and dates left blank, and varying levels of assistance recorded, indicating a lack of consistent care. R34 was admitted with multiple diagnoses, including a displaced bimalleolar fracture and severe cognitive impairment, requiring setup or clean-up assistance for oral hygiene. Despite this, there was no specific care plan addressing R34's oral hygiene needs, and the Assistant Director of Nursing confirmed that oral care should be part of morning care. The facility's oral care documentation was found to be incomplete and inconsistent, with no refusals of care documented. The Assistant Director of Nursing and the MDS Coordinator acknowledged the deficiencies in documentation and care provided to R34.
Failure to Administer Medications to Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that medications were available for administration to a newly admitted resident, identified as R143. On the day following their admission, R143 was not administered several prescribed medications, including doxycycline hyclate, midodrine, famotidine, ascorbic acid, Banatrol Plus, ferrous sulfate, and alpha lipoic acid. The resident, who had been admitted with diagnoses of Retention of Urine and Encounter for fitting and adjustment of a urinary device, was observed with a catheter draining amber-colored urine. The Medication Administration Record (MAR) for March 2025 indicated that these medications were on order but not administered as scheduled. During an interview, the Assistant Director of Nursing (ADON) explained that the admitting nurse is responsible for entering medication orders into the electronic medical record and reconciling them with the medical provider during the admission assessment. The ADON noted that the admitting nurse should have arranged for a STAT delivery from the pharmacy or checked the backup box to ensure timely administration of medications. However, no further information was provided by the end of the survey regarding why the medications were not available for R143.
Lack of Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that physician orders were in place and appropriate catheter care was provided for a resident with an indwelling catheter. The resident, identified as R143, was observed on multiple occasions with their catheter tubing dragging on the floor and not secured properly, which could lead to potential complications. The resident's medical record indicated a diagnosis of urine retention and the use of a suprapubic catheter, but there were no active physician orders for the care or monitoring of the catheter. During the review of the medical record with Nurse E, it was confirmed that there were no orders for the care of R143's catheter, and it was noted that the admitting nurse should have entered these orders. The Assistant Director of Nursing (ADON) acknowledged that the orders should be entered during the initial evaluation by the admitting nurse to ensure proper documentation and care. Despite the acknowledgment of the issue, no further information or corrective action regarding the lack of physician orders was provided by the end of the survey.
Failure to Implement and Communicate Proper Infection Control Precautions
Penalty
Summary
Surveyors observed that a resident with multiple medical conditions, including influenza and a right artificial knee joint, was not provided with appropriate infection control measures during therapy and care activities. On one occasion, there was no Enhanced Barrier Precautions (EBP) signage or PPE cart available in the resident's room, despite the resident later being placed on EBP. When the PPE cart was present, it was inadequately stocked, containing only gowns and lacking gloves and hand sanitizer. Physician orders for EBP were not written until after these deficiencies were observed, and care plans did not address the resident's need for EBP or droplet precautions following a positive influenza diagnosis. Documentation revealed that the resident developed a wound on the right knee with purulent drainage, yet infection control protocols were not consistently implemented. Staff interviews indicated confusion and inconsistency regarding the use of PPE and the posting of appropriate signage. The infection preventionist and DON acknowledged that staff actions did not align with facility policy or training, and that signage in use did not specify the type of precautions or required PPE, instead instructing individuals to 'see nurse' for information. This created uncertainty for staff and visitors about the necessary infection control measures, especially when a nurse was not immediately available. Facility documents outlined clear requirements for PPE availability, signage, and procedures for both EBP and droplet precautions, but these were not followed in practice. The lack of accessible and specific precaution signage, incomplete PPE supplies, and delayed implementation of physician orders and care plans contributed to the deficiency in infection control practices for the resident. These failures were confirmed by both the infection preventionist and DON during interviews.
Missing Required Signage on Delayed Egress Doors
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors in a required means of egress were properly equipped according to regulatory requirements. Specifically, on March 12, 2025, at approximately 10:10 AM, it was found that the 2nd floor stairwell exit doors 1, 2, and 3, which were equipped with 15-second delayed egress locking systems, did not have the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." This signage is necessary to inform individuals of the delayed egress function and how to operate the doors in an emergency. The deficiency was confirmed at the time of observation and interview by the Director of Maintenance and Security and the Maintenance Director. The lack of proper signage on these egress doors constitutes non-compliance with NFPA 101 2012 edition requirements, specifically sections 19.2.2.2.5.1, 19.2.2.2.6, and 7.2.1.6.1.1 (4). This issue could affect all 39 residents in the event of a fire emergency, as the absence of clear instructions may impede timely evacuation.
Failure to Maintain and Test Sprinkler System per NFPA 25
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler system in accordance with NFPA 25 standards. Specifically, observation revealed that the gauge for the sprinkler riser was dated 2019, indicating it had not been replaced or recalibrated within the required five-year interval. Additionally, record review showed that the facility did not provide documentation for the required 5-year check valve and internal pipe tests for the automatic wet sprinkler system. When requested, the Maintenance Director stated that these tests were scheduled for the following month, but no documentation was available at the time of the survey exit. These deficiencies were confirmed by the Director of Maintenance and Security, Security Manager, and Maintenance Director during the survey.
Failure to Repair and Locate Fire Dampers in HVAC System
Penalty
Summary
The facility failed to ensure that its heating, ventilation, and air conditioning (HVAC) system was in compliance with NFPA 80, 2010 Edition, 19.4, as required. During a record review on March 12, 2025, it was found that the facility had not repaired fire dampers identified in a document titled "Duct Cleaning" from March 2023. The report specifically noted that some fire dampers were inaccessible and could not be located. These findings were confirmed during an interview with the Director of Maintenance and Security and the Maintenance Director at the time of the record review. This deficiency could potentially affect all 39 residents in the event of a fire, as the proper functioning and accessibility of fire dampers are critical for fire safety within the facility.
Failure to Maintain Required Elevator Firefighter's Service Testing Records
Penalty
Summary
The facility failed to ensure that elevators were inspected and tested according to the required standards, specifically ASME A17.1 and ASME/ANSI A17.3, including the monthly operation and documentation of the firefighter's service. During a record review, surveyors found that there was no written record of the monthly firefighter's service tests for the elevators. When questioned, the Maintenance Director stated that this was the first time they had heard about the requirement, and no documentation was available at the time of the survey exit. These findings were confirmed by both the Director of Maintenance and Security and the Maintenance Director during the review and interview. This deficiency could potentially affect all 39 residents in the event of an emergency, as the required elevator safety checks and documentation were not maintained.
Failure to Conduct Fire Drills at Unexpected Times
Penalty
Summary
The facility failed to conduct fire drills at unexpected times as required by regulations 19.7.1.4 through 19.7.1.7. Record review on May 12, 2023, showed that first shift fire drills for the 2nd and 3rd quarters were both conducted in the early afternoon, while third shift fire drills for the 1st, 2nd, and 4th quarters were all conducted in the early morning hours. This pattern indicates that fire drills were not held at varying and unexpected times as mandated. These findings were confirmed during interviews with the Director of Maintenance and Security and the Maintenance Director at the time of record review. All 39 residents in the facility could be affected by this deficient practice in the event of a fire emergency, as staff may not be adequately prepared for fire situations occurring at truly unexpected times.
Failure to Provide Annual Generator Diesel Fuel Analysis Documentation
Penalty
Summary
The facility failed to provide documentation for the annual generator diesel fuel analysis as required by NFPA 110, NFPA 99, NFPA 111, and NFPA 70. During a record review on March 12, 2025, surveyors requested the document verifying that the annual analysis had been completed, but the Maintenance Director confirmed that the document was not available. No documentation was produced by the time the survey concluded. This deficiency affects the facility's compliance with essential electrical system maintenance and testing requirements, which are critical for ensuring the generator or alternate power source is capable of supplying emergency power within the required timeframe. The lack of documentation could impact all 39 residents in the event of a fire emergency, as the facility could not demonstrate adherence to required safety standards.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to comply with NFPA 99 requirements for the storage of nonflammable gases. During an observation, it was found that nine oxygen concentrators were stored less than five feet from oxygen cylinders in the designated Oxygen Room. NFPA 99 specifies that there must be at least a five-foot separation between combustibles or materials housed in the same area as oxygen cylinders, or appropriate fire-rated enclosures must be used. This deficiency was identified through direct observation and confirmed by both the Director of Maintenance and Security and the Maintenance Director during the survey. The improper storage arrangement could affect six occupants in the event of a fire, as noted in the report. The surveyors documented that the facility did not ensure the required separation between oxygen concentrators and oxygen cylinders, which is a direct violation of the cited code. No information was provided regarding the medical history or condition of the affected occupants at the time of the deficiency.
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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.
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Nursing homes near Novi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Manor Rehab Center Of Novi Inc | 1.1 mi | ★★★★★ | 2 | 0 |
| Novi Lakes Health Campus | 1.1 mi | ★★★★★ | 0 | 0 |
| The Manor Of Novi | 3 mi | ★★★★★ | 22 | 0 |
| Marvin & Betty Danto Health Care Center | 3.2 mi | ★★★★★ | 6 | 0 |
| Notting Hill Of West Bloomfield | 3.5 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.