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 Maple Manor Rehab Center Of Novi Inc during CMS and state inspections, most recent first.
Surveyors identified that the facility failed to maintain clean and homelike conditions in two residents’ rooms and in central spa areas. One resident’s room floor was covered with old food debris and had peeling baseboards and drywall, while another resident’s room floor was sticky with darkened dirt spots. In multiple shower rooms, shower mats were worn and cracked, a light bulb was burned out, caulk was missing with black mold-like soiling at floor/wall junctions, a bleach disinfectant unit was stored next to a sink, and personal care items were stored on sinks. Facility policies required a sanitary, orderly, comfortable environment and adequate lighting but did not specifically address cleaning and disinfection of central spa areas.
A high fall-risk resident with a history of femur fracture and multiple comorbidities was care-planned to ambulate with CGA and a walker, as indicated by a red tag on the walker and facility policy requiring gait belt use for residents who cannot ambulate independently. One night, a CNA assisted the resident to the bathroom and then allowed the resident to walk back toward the bed without using a gait belt and without maintaining contact guard, remaining too far away to intervene when the resident lost balance, became entangled in the walker, and fell. The resident was found on the floor with multiple skin tears and a bleeding forehead laceration that required hospital treatment and sutures. Subsequent interviews with the CNA, Rehab Director, and DON confirmed that the resident should have had hands-on CGA and likely a gait belt during ambulation, but these interventions were not implemented at the time of the fall.
During an influenza outbreak, the facility failed to implement consistent infection control practices and an effective surveillance program. Staff did not adhere to PPE protocols, and the Infection Control Preventionist provided inconsistent guidance. The facility's infection surveillance was incomplete, and there was a delay in reporting the outbreak to the health department. Specific incidents included staff entering precaution rooms without proper PPE and inadequate equipment cleaning, contributing to the facility's failure to control the outbreak.
The facility's wireless call light system was not fully operational, affecting all residents' ability to summon help. Residents, including those with significant medical needs, reported long wait times and ineffective alternative solutions like bells. Staff interviews and observations revealed issues with the system's Wi-Fi connection and lack of regular audits, leading to unreliable service. The facility's policy on call light accessibility and timely response was not met due to these deficiencies.
Two residents in a LTC facility were found with position change alarms without appropriate assessments or physician orders. One resident, with Alzheimer's, had alarms in their wheelchair and bed without documented justification or attempts at less restrictive measures. Another resident, cognitively intact, had a bed alarm despite being able to request assistance. Interviews revealed inconsistencies in the facility's process for alarm use, and the Director of Nursing acknowledged the lack of documentation and assessments.
A resident with quadriplegia and hand contractures was observed without required hand splints, despite a care plan indicating their use. Staff interviews revealed inconsistency and lack of awareness regarding the splints, with some using rolled washcloths instead. The Director of Rehab and DON were unaware of the splints' status, highlighting a lack of oversight in implementing the care plan.
A facility failed to consistently administer oxygen therapy as ordered for a resident with sepsis and delirium. The resident was observed with disconnected or improperly placed oxygen tubing on two occasions, contrary to the physician's order for oxygen via nasal cannula at 2 LPM. Despite the need for assistance with all ADLs, no care plan or interventions were documented for the resident's non-compliance with oxygen therapy. The DON was unaware of the issue and stated that interventions could have been implemented if informed.
The facility failed to document indications for medications for two residents, contrary to its policy. One resident, readmitted with a femur fracture, had orders for Bupropion, Trazodone, and Xanax without indications. Another resident, with atrial flutter and heart failure, had orders for Eliquis and Hydrocodone-acetaminophen also lacking indications. The DON acknowledged the issue and mentioned plans to ensure indications are documented in the future.
The facility failed to ensure PRN psychotropic medications had a stop date and did not attempt non-pharmacological interventions before administration for two residents. One resident received alprazolam without an end date, and another received Xanax beyond the 14-day limit without justification. The facility's policy requires PRN orders to be limited to 14 days and non-pharmacological interventions to be attempted first, which was not followed.
The facility did not maintain a system to monitor antibiotic use, affecting residents prescribed antibiotics. The February 2025 Infection Control Form showed incomplete documentation, with infections not assessed for criteria, resolution, or origin. The ICP was too busy to maintain data and relied on McGeer checklists at nurses' stations. The facility's policy on the Antibiotic Stewardship Program was not effectively implemented.
A resident with intact cognition and a history of orthostatic hypotension and shingles was placed on a position change alarm without a physician order, care plan intervention, or documented assessment, contrary to facility policy. Staff interviews revealed confusion about alarm use procedures, and the DON confirmed the lack of documentation. Additionally, a CNA failed to follow contact precautions and infection control protocols when entering the resident's room, including not using PPE or performing hand hygiene.
Two residents received PRN anti-anxiety medications with open-ended orders and without required documentation justifying use beyond 14 days. Medical records lacked evidence of non-pharmacological interventions being attempted or documented prior to medication administration, contrary to facility policy. The DON acknowledged these deficiencies during interviews.
Surveyors found that staff inconsistently followed droplet precaution protocols for two residents with influenza, including improper use of PPE and inadequate cleaning or dedication of equipment. Staff interviews revealed confusion about required PPE and cleaning procedures, and signage did not align with facility policy, resulting in deficient infection control practices.
Several residents with significant care needs were unable to reliably summon staff due to a malfunctioning wireless call light system, which frequently lost WiFi signal and lacked regular maintenance checks. Residents resorted to using hotel-like bells that were not audible when doors were closed, and staff were not consistently notified of calls for assistance. Staff interviews confirmed that pagers and alert systems were not always used or functional, and maintenance only responded to complaints rather than conducting routine audits.
A facility failed to maintain consistent dialysis communication documentation and assessments for a resident with end-stage renal disease. The last documented dialysis communication/assessment was nearly a year old, despite the resident receiving dialysis care five days a week. The DON confirmed that the records had not been uploaded to the resident's medical record since May 2023.
The facility failed to provide a privacy cover over an indwelling catheter bag for a resident. On multiple occasions, the resident was observed without a dignity privacy bag covering the catheter bag. The DON confirmed that the resident should have had a dignity privacy bag and that nursing staff are responsible for ensuring these are in place. The resident had diagnoses of Neuromuscular Dysfunction of the Bladder, Multiple Sclerosis, and Paraplegia, and was cognitively intact.
The facility failed to ensure that the code status and treatment preferences of three residents were clearly documented in their clinical records, leading to inconsistencies between the hard chart and the EMR.
A resident with hearing loss and hearing aids did not have a care plan addressing these concerns. The MDS Coordinator acknowledged the oversight, and the DON confirmed that it was the MDS Coordinator's duty to create the care plan.
A resident with a traumatic brain injury and severely impaired cognition had multiple instances of redness and open skin on the coccyx and buttocks documented in the MAR from February to April 2024. However, there was no documented assessment of the wounds, and an observation revealed bloody drainage and partial thickness skin loss, contradicting earlier documentation that the wound had resolved.
The facility failed to consistently document urinary output for a resident with an external catheter, despite the care plan requiring monitoring and documentation every shift. The DON confirmed the requirement, but multiple instances of undocumented outputs were found across January, February, and March 2024.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident was prescribed antibiotics for a productive cough associated with COVID-19 without documented justification, while another was given Cipro for a UTI despite a negative urine culture. Interviews revealed that the facility did not review antibiotics prescribed at the hospital, leading to inadequate documentation and adherence to protocols.
Failure to Maintain Clean, Safe, and Homelike Resident and Spa Environments
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, and homelike environment in resident rooms and central shower areas. One resident’s room floor was observed to be covered with old food debris, and the resident reported that housekeeping was not doing a good job of mopping the floor. In the same room, the baseboard by the hand sink and the corner drywall strips were observed to be peeling away from the wall, and these conditions were still present during a subsequent observation two days later. Another resident’s room floor was observed to be sticky with darkened dirt spots covering it. During a building tour of the central spa areas with the Director of Maintenance and a Maintenance Technician, multiple environmental issues were observed. Shower mats in two shower rooms were worn, cracked, and no longer smooth and cleanable. A light bulb was burned out in one shower area. At the floor/wall juncture in two shower rooms, caulk was missing and the area was soiled with a black mold-like substance. A disinfectant unit/cart containing a bleach product was stored next to the sink in one shower room, and several bottles of personal care items such as soaps and shampoos were stored on the sinks in all spa rooms. Review of the facility’s Routine Cleaning and Disinfection policy showed it did not address cleaning and disinfection of the central spa areas, while the Safe and Homelike Environment policy required housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment and to provide adequate lighting and prompt reporting of furniture in disrepair.
Failure to Provide Required Contact Guard Assist and Gait Belt Use Resulting in Resident Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement required fall-prevention interventions and adequate supervision for a high fall-risk resident, resulting in a fall with injuries. The resident was admitted with a history of a fall with femur fracture and other diagnoses including diabetes, COPD, UTI, urinary retention, and adjustment disorder. A fall risk assessment completed in December scored the resident as an 18, which the facility defined as high fall risk. The resident’s walker had a red tag indicating the need for contact guard assist (CGA) and use of a gait belt when ambulating, and the facility’s policy required residents who could not independently ambulate or transfer to use a gait belt for safety. On the night of the incident, a nurse documented that around 1:15 a.m. a loud sound was heard from the resident’s room, and the nurse found the resident sitting on the floor with the walker between their legs, bleeding from the forehead with a right arm skin tear and bilateral leg skin tears. The resident was sent to the hospital and later returned with sutures to the forehead, bruising to the left temporal area, and dressings and steri-strips to multiple skin tears. A physician note referenced a mechanical fall with scalp laceration requiring sutures. The resident and family later reported via a complaint form that the resident, who used a walker and was recovering from surgical repair of a broken femur, had been assisted to the bathroom by an aide and fell while walking back toward the bed because the aide did not physically support the resident. During the facility’s investigation, the resident initially alleged that the CNA pushed them, but provided inconsistent statements. Another CNA reported that the resident and the resident’s daughter stated the aide involved was not close enough to prevent the fall. In a telephone interview, the CNA who assisted the resident acknowledged answering the call light, assisting the resident to the bathroom, and then allowing the resident to ambulate back to the bed with a walker. The CNA stated the resident lost balance while backing toward the bed, became tangled in the walker, and fell, and admitted they were not close enough to get a hand on the resident to prevent the fall. The CNA further acknowledged knowing the red tag on the walker meant the resident required CGA and a gait belt, but they did not provide contact guard assist or use a gait belt at the time of the fall. The Rehabilitation Director and DON both confirmed that CGA required staff to be right next to the resident with a hand on or near them and that a gait belt should have been used for this resident.
Inadequate Infection Control During Influenza Outbreak
Penalty
Summary
The facility failed to consistently implement infection control standards and practices, as well as an effective infection control surveillance program, during an influenza outbreak affecting all 47 residents. Upon entry, surveyors were informed of the outbreak and observed inadequate infection control measures, such as staff not wearing the required personal protective equipment (PPE) like gowns, despite signage indicating droplet precautions. The Infection Control Preventionist (ICP) and staff provided inconsistent information regarding PPE requirements, and the facility's policy was not followed, leading to potential exposure risks. The infection surveillance program was found lacking, with no documentation for February 2025 and incomplete mapping of infections from May 2024 to March 2025. The ICP admitted to taking surveillance documents home due to covering two buildings, resulting in delayed reporting to the local health department. The facility failed to timely identify, report, and control the outbreak, as evidenced by the delayed notification of the health department and the lack of real-time infection control data review, despite the ongoing outbreak. Specific incidents highlighted the facility's deficiencies, such as a CNA entering a resident's room under contact precautions without proper PPE and failing to perform hand hygiene. Another staff member was observed improperly cleaning equipment used in a droplet precaution room, and there was confusion among staff about the correct PPE protocol. These actions and inactions contributed to the facility's failure to adhere to infection control standards, potentially exacerbating the outbreak and putting residents and staff at risk.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that its wireless call light communication system was fully operational, affecting all residents, including those with significant medical needs. Observations revealed that residents were unable to summon help effectively due to the malfunctioning call light system. For instance, one resident, who was in pain and waiting for medication, reported that their call light was not functioning, and their roommate had to use a bell to attempt to summon help. Another resident expressed concerns about the ineffectiveness of the bell provided as an alternative, especially with doors closed due to a flu outbreak. The facility's call light system was found to be unreliable, with issues such as loss of Wi-Fi signal and incorrect date and time settings on the alert system. Staff interviews confirmed that the system frequently lost connection, and pagers, which were part of the system, were not being used consistently. Maintenance staff admitted to not conducting regular audits of the call light system, instead relying on complaints to address issues. This lack of proactive monitoring contributed to the ongoing problems with the call light system. The facility's policy required that call lights be accessible and that staff respond promptly to alerts. However, the system's deficiencies, including the lack of a hard-wired connection and reliance on a faulty wireless network, hindered compliance with this policy. The Director of Nursing and Assistant Administrator acknowledged the system's shortcomings and the need for a new system, but at the time of the survey, the existing system remained inadequate, leaving residents without a reliable means to summon assistance.
Failure to Document and Justify Use of Position Change Alarms
Penalty
Summary
The facility failed to ensure appropriate assessments and physician orders were completed for the use of position change alarms for two residents, R6 and R342. R6 was admitted with multiple diagnoses including Alzheimer's disease and was observed with a position change alarm in both their wheelchair and bed. However, there was no documentation in R6's electronic medical record (EMR) indicating a medical symptom or diagnosis that warranted the use of these alarms. Additionally, there was no evidence of any least restrictive approaches being attempted prior to the use of the alarms, nor were there any nursing or interdisciplinary assessments recommending their use. R6's care plan did not mention the use of position change alarms, and the facility's progress notes lacked any rationale for their use. R342, admitted for short-term skilled nursing and rehabilitation care, was also observed with a position change alarm attached to their bed. Despite having a history of near falls due to orthostatic hypotension, R342 was cognitively intact and able to ask for assistance. The EMR for R342 did not contain any orders for the use of position change alarms, nor did it document any medical symptoms justifying their use. Similar to R6, there was no evidence of any nursing or interdisciplinary assessments recommending the alarms, and no documentation of other less restrictive measures being attempted. R342's care plan and Minimum Data Set (MDS) assessment did not mention the use of position change alarms. Interviews with Certified Nursing Assistants (CNAs) and the Director of Nursing (DON) revealed a lack of clarity and consistency in the facility's process for determining the use of position change alarms. The CNAs indicated that alarms were used for residents deemed at risk of falls, but they were unsure of the process and who made the final determination. The DON acknowledged the absence of documentation and assessments for R6 and R342, understanding the concern raised by the surveyors. The facility's policy on resident alarms emphasized the need for alarms to be used in limited circumstances, based on a comprehensive assessment of the resident's needs, goals, and preferences, which was not adhered to in these cases.
Failure to Implement Hand Splints for Resident with Contractures
Penalty
Summary
The facility failed to implement a positioning device, specifically hand splints, for a resident (R16) who was reviewed for positioning and range of motion services. R16, a long-term resident with a history of traumatic brain injury, quadriplegia, and seizures, was observed multiple times without any hand splints or braces, despite having bilateral hand contractures. The care plan for R16, initiated in September 2020, required the use of splints on both hands at night to prevent injury, skin breakdown, edema, atrophy, and contractures. However, observations on consecutive days revealed that R16's hands remained in a clawed position without any splints or devices in place. Interviews with staff members, including an LPN and a CNA, indicated a lack of awareness and inconsistency in the use of hand splints for R16. The LPN, who was familiar with R16, reported never having seen any splints for the resident and confirmed their absence in the room. Similarly, the CNA, who regularly worked with R16, noted that the use of rolled washcloths was inconsistent and dependent on the staff member assigned to the resident. The CNA care plan did mention the requirement for hand splints, but the actual practice did not reflect this plan. Further interviews with the Director of Rehab and the Director of Nursing revealed a lack of oversight and follow-up regarding the implementation of the care plan for R16. The Director of Rehab was unaware of the current status of R16's splints and suggested that the splints might have been missed after the resident's readmission from the hospital. The Director of Nursing acknowledged the concern and the absence of a plan to maintain R16's range of motion, indicating a gap in ensuring that CNAs followed the care plan and documented appropriately.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that oxygen therapy was consistently administered as ordered by the physician for a resident identified as R14. On two separate occasions, R14 was observed with their oxygen tubing disconnected or improperly placed, which was not in accordance with the physician's order for oxygen via nasal cannula at 2 LPM to maintain an oxygen saturation of 90% or greater. The first incident occurred when R14 was found with the oxygen tubing disconnected from the concentrator, and the LPN had to reconnect it. The LPN mentioned that R14 often removed the tubing themselves. The second incident involved R14 sleeping with the nasal cannula improperly placed on their upper lip, requiring an RN to reapply it and remind R14 to keep it on. The medical record review revealed that R14 was admitted with diagnoses including sepsis and delirium and required assistance for all ADLs. Despite the physician's order for oxygen therapy, there was no care plan or interventions documented for R14's non-compliance with oxygen therapy. The facility's policy on oxygen administration requires that care plans identify interventions for oxygen therapy based on assessments, but this was not implemented for R14. The Director of Nursing was unaware of R14's non-compliance and stated that interventions could have been implemented if they had known about the issue.
Failure to Document Indications for Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications had an indication for use and did not transcribe physician orders according to the facility policy for two residents. Resident 5 was observed receiving oxygen via nasal cannula and had been readmitted with a diagnosis of a fracture of the lower end of the left femur. The medical record review showed that the physician orders for Bupropion, Trazodone, and Xanax did not include an indication for use, with staff documenting 'N/A' in the diagnosis section. This was contrary to the facility's medication order policy, which requires a diagnosis or indication for use. Similarly, Resident 7, who was readmitted with atrial flutter and heart failure, had physician orders for Eliquis and Hydrocodone-acetaminophen that also lacked documented indications for use, with 'N/A' noted in the diagnosis section. During an interview, the Director of Nursing acknowledged that the indications are typically included in the physician's progress notes and stated that a process would be implemented to ensure the indication section is completed when transcribing medication orders. No further explanation or documentation was provided by the end of the survey.
Failure to Implement PRN Psychotropic Medication Protocols
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications had a stop or end date and did not attempt non-pharmacological interventions before administering these medications to two residents, R5 and R12. R12, who was admitted with multiple diagnoses including generalized anxiety disorder, was prescribed alprazolam on a PRN basis without an end date. The medication was administered multiple times over a month for reasons such as behavior issues and pain, but there was no evidence of non-pharmacological interventions being attempted prior to its administration. The Director of Nursing (DON) acknowledged the lack of an end date and the absence of documentation for non-pharmacological interventions. Similarly, R5 was prescribed Xanax on a PRN basis with an open-ended order, which extended beyond the 14-day limit without documented justification from the prescribing practitioner. The medication was administered on several occasions, yet there was no documentation of non-pharmacological interventions being attempted before its use. The DON confirmed that the order should have had a stop date and that staff should have documented interventions prior to administering the medication. The facility's policy on the use of psychotropic medications, revised in January 2025, stipulates that PRN orders for such medications should be limited to 14 days unless extended with documented rationale. It also requires non-pharmacological interventions to be attempted before administering psychotropic medications. The facility's failure to adhere to these policies resulted in deficiencies related to the administration of PRN psychotropic medications for R5 and R12.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to consistently maintain a system that monitored antibiotic use, potentially affecting any resident prescribed an antibiotic among the 47 residents in the facility. A review of the facility's February 2025 Infection Control Form revealed five pages of documented infections, none of which were assessed to meet or not meet the criteria for infection, with sections left blank. Additionally, infections were not identified as resolved, ongoing, nosocomial, or community-acquired, and signs and symptoms were often not noted. The surveillance log was incomplete. The Infection Control Preventionist (ICP) admitted to being too busy to maintain the data and relied on the McGeer checklist posted at nurses' stations for guidance, without further explanation. The facility's policy on the Antibiotic Stewardship Program, revised in January 2025, stated the use of updated McGeer criteria to define infections, but this was not effectively implemented.
Failure to Document and Assess Use of Position Change Alarms and Lapses in Infection Control
Penalty
Summary
A resident was admitted to the facility following hospitalization, with diagnoses including orthostatic hypotension, muscle weakness, and later, shingles. The resident was cognitively intact, able to use the call light, and could request assistance. Despite this, a position change alarm was observed in use for the resident, with no corresponding physician order, care plan intervention, or interdisciplinary assessment recommending its use. Documentation in the electronic medical record did not support the use of the alarm, and there was no evidence that less restrictive interventions were attempted prior to its implementation. Staff interviews revealed uncertainty about the process for determining alarm use, with CNAs indicating that alarms were often used for fall risk residents, sometimes at their own discretion, and without clear guidance or assessment documentation. The facility's policy required that alarms be used only in limited circumstances, based on individualized assessment, documented medical symptoms, and after considering less restrictive interventions. However, the resident's records lacked documentation of such assessments, orders, or care plan entries for the alarm. The DON confirmed that there was no documentation supporting the use of alarms for the resident and acknowledged the concern. The policy also required communication of interventions to all relevant staff, which was not evident in this case. Additionally, infection control deficiencies were observed. The resident was on contact precautions due to a diagnosis of shingles, with clear signage and physician orders requiring hand hygiene and the use of personal protective equipment (PPE) upon entering the room. A CNA was observed entering the resident's room without performing hand hygiene or donning PPE, touching the resident's environment, and improperly handling their face mask. The CNA was unaware of the correct reason for contact precautions and did not follow required infection control protocols, despite care plan and physician order instructions.
Failure to Limit and Document PRN Psychotropic Medication Use and Non-Pharmacological Interventions
Penalty
Summary
Two residents were found to have ongoing PRN (as needed) orders for anti-anxiety medications, specifically alprazolam and Xanax, without appropriate stop dates or documented clinical justification for extending the orders beyond 14 days. The facility's own policy, consistent with federal regulations, requires that PRN psychotropic medications be limited to 14 days unless the prescribing practitioner documents a rationale for extension and specifies a duration. In both cases, the orders were open-ended and lacked the required documentation from the prescribing practitioner to justify continued use beyond the 14-day limit. Additionally, the medical records for both residents did not contain evidence that non-pharmacological interventions were attempted or documented prior to the administration of the PRN psychotropic medications. The facility's policy mandates that non-pharmacological approaches be used and documented before resorting to psychotropic medications unless clinically contraindicated. However, the Medication Administration Records (MAR) and nursing progress notes did not reflect any such interventions or monitoring of target behaviors before administering the medications. Interviews with the Director of Nursing (DON) confirmed awareness of the requirements for stop dates and documentation of non-pharmacological interventions, but acknowledged that these were not followed in the cases reviewed. The lack of adherence to policy and regulatory requirements regarding psychotropic medication management and documentation led to the identified deficiencies.
Deficient Infection Control Practices for Droplet Precautions
Penalty
Summary
Surveyors observed that a resident's room was under droplet precautions for influenza, as indicated by signage and the presence of a PPE cart outside the room. Staff interviews revealed inconsistent understanding and implementation of droplet precaution protocols. The Infection Preventionist stated that staff should wear a surgical mask, face shield, and gown, but the signage only required a mask and face shield, and staff reported that gown use was optional or no longer required. A physical therapy assistant was seen donning a gown, gloves, and mask, but only sanitized the finger area of a vital sign machine after use in the resident's room, despite signage indicating the need for dedicated or disposable equipment. The assistant confirmed that there was no dedicated equipment for that area and that only part of the machine was cleaned before it was taken into the hallway. Further interviews with staff showed confusion about proper PPE donning and doffing procedures, with some staff stating that gowns were not necessary and that face shields should be cleaned in the hallway rather than in the resident's room. The Infection Preventionist clarified that face shields should be cleaned in the room, but this was not consistently practiced. The residents involved had recent diagnoses of influenza and other significant medical conditions, and one resident confirmed ongoing illness. The observations and interviews demonstrate a deficiency in the facility's implementation and staff understanding of infection control protocols for droplet precautions, including the use of PPE and cleaning or dedicating equipment.
Failure to Maintain Functional Call Light System for Resident Safety
Penalty
Summary
Multiple residents were observed to have non-functioning or unreliable call light systems in their rooms, which impeded their ability to request assistance from staff. One resident, who had intact cognition and required assistance with most activities of daily living, reported that their call light did not work and that maintenance had attempted repairs several times without success. This resident resorted to using a hotel-like bell, which was not audible when the door was closed, and staff did not respond to the bell on at least one occasion. Another resident, who was wearing a sling and used a wheelchair, also relied on a hotel-like bell and expressed uncertainty about whether the call lights in their room and bathroom worked. This resident reported having to wait longer for staff assistance and sometimes asked staff to leave the bathroom door open so they could call for help verbally. A third resident, who had a tracheostomy and communicated by typing on a cell phone, also used a hotel-like bell and reported delays in receiving assistance after calling for help. Staff interviews revealed that the call light system was dependent on a wireless network, which frequently lost signal, and that pagers, which were part of the system, were not consistently used or functional. The call light alert box at the nursing alcove displayed incorrect dates and times, and staff were unable to determine how long it took to respond to calls or if someone else had turned off the alert. Maintenance staff confirmed that the system was not hard-wired, was reliant on WiFi, and that no regular audits were conducted to ensure functionality; instead, they responded only to complaints. Facility policy required that call lights be accessible and functional at each resident's bedside, toilet, and bathing facility, and that staff be educated on their use. However, observations and interviews indicated that the system did not consistently alert staff, alternative bells were not effective, and staff were not always aware of or using all components of the system. Documentation from the system manufacturer recommended monthly testing of personal help buttons, but maintenance staff did not perform routine checks. The deficiency was further evidenced by the lack of hallway or in-room call light indicators and the facility's reliance on resident complaints to identify issues.
Failure to Maintain Consistent Dialysis Documentation
Penalty
Summary
The facility failed to ensure consistent dialysis communication documentation and assessments were maintained in the clinical record for a resident who required dialysis services. The resident, who was readmitted with a diagnosis of end-stage renal disease, reported receiving dialysis care five days a week at the bedside. However, a review of the medical record revealed that the last documented dialysis communication/assessment was dated nearly a year prior. The Director of Nursing confirmed that the dialysis entity emails the documentation to the facility but acknowledged that the records had not been uploaded to the resident's medical record since May 2023. The deficiency was identified during an observation and interview with the resident, as well as a review of the medical record and an interview with the Director of Nursing.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to provide a privacy cover over an indwelling catheter bag for one resident (R2). On multiple occasions, R2 was observed without a dignity privacy bag covering the catheter bag. Specifically, on 4/22/24 at 9:31 AM and on 4/23/24 at 8:43 AM, R2 was seen in bed with the catheter bag exposed. The Director of Nursing (DON) confirmed on 4/24/24 at 1:09 PM that R2 should have had a dignity privacy bag and that nursing staff are responsible for ensuring these are in place. R2's medical record indicated diagnoses of Neuromuscular Dysfunction of the Bladder, Multiple Sclerosis, and Paraplegia, and the resident was cognitively intact with a Brief Interview of Mental Status score of 13/15. The facility's policy on promoting and maintaining resident dignity, revised in 11/2023, mandates maintaining resident privacy, which was not adhered to in this case.
Failure to Document Residents' Code Status and Treatment Preferences
Penalty
Summary
The facility failed to ensure that the code status and treatment preferences of three residents were clearly documented in their clinical records. Resident 46 had a signed advance directive indicating Do-Not-Resuscitate (DNR) status, but this was not flagged in the electronic medical record (EMR). The Director of Nursing (DON) and Social Worker provided conflicting information about the resident's code status, with discrepancies between the hard chart and the EMR. The Social Worker reported that the resident had changed their code status to full code upon readmission, but this was not accurately reflected in the records. Resident 48's clinical record did not have a code status flagged in the EMR, and no advance directive form was initially found in the EMR. The resident's social services assessment indicated a full code status, but this was not documented in the EMR. The facility later uploaded an advance directive form indicating the resident's wishes, but it was discovered that the form was only in the binder on the unit and not in the EMR prior to questioning. Resident 108's clinical record also lacked a flagged code status in the EMR and did not have an advance directive form indicating the resident's treatment wishes. The DON later uploaded an advance directive form into the EMR, which indicated the resident's full code status and other treatment preferences. The form was found in the binder on the unit but was not initially in the EMR. The facility's policy on residents' rights regarding treatment and advance directives was not followed, leading to inconsistencies in the documentation of residents' treatment preferences.
Failure to Develop and Implement Hearing Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with hearing loss. The resident was admitted with a diagnosis of hearing loss in the right ear and had hearing aids. Despite this, the resident's comprehensive care plan did not address hearing concerns or the use of hearing aids. The deficiency was identified during an interview with the MDS Coordinator, who acknowledged that the care plan for hearing concerns was missed and was only added to the EMR after it was overheard that the resident did not have a care plan for hearing aids. The Director of Nursing confirmed that the resident should have had a hearing care plan and that it was the MDS Coordinator's responsibility to create it.
Failure to Thoroughly Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to thoroughly assess and document a pressure ulcer for a resident with a traumatic brain injury and severely impaired cognition. The resident was dependent on staff for all activities of daily living, including bed mobility and transfers. Despite having an active physician's order for Venelex ointment to be applied to the coccyx, there was no documentation of wound care progress since 2020. The Medication Administration Records (MAR) indicated multiple instances of redness and open skin on the coccyx and buttocks from February to April 2024, but no measurements or characteristics of the wounds were documented. Interviews with the wound care coordinator and the Director of Nursing (DON) revealed that weekly skin assessments were supposed to be documented on the MAR, and any wounds were to be evaluated by a physician. However, both the wound care coordinator and the DON confirmed that there was no documented assessment of the resident's wounds. An observation on April 24, 2024, revealed bloody drainage and partial thickness skin loss on the resident's coccyx, contradicting the nurse practitioner's earlier documentation that the wound had resolved. The nurse practitioner had documented the presence of a Stage IV sacral and ischial ulcer with minor bleeding in January and February 2024, but later notes in March and April 2024 indicated that the wound had resolved. Despite this, the observation on April 24, 2024, showed open areas and bloody drainage, indicating a lack of accurate and timely documentation. The facility's policy on skin assessment required detailed documentation of wound characteristics, which was not followed in this case.
Failure to Document Urinary Output for Resident with External Catheter
Penalty
Summary
The facility failed to document urinary output consistently for a resident with an external catheter. The resident, who had medical diagnoses including Neuromuscular Dysfunction of the Bladder, Multiple Sclerosis, and Paraplegia, required maximal assistance with bed mobility, toileting hygiene, and transfers. The resident's care plan specified that urine odor, color, amount, and sediment should be monitored and documented every shift. However, a review of the Treatment Administration Record (TAR) for January, February, and March 2024 revealed multiple instances where urinary output was not documented for both day and night shifts. The Director of Nursing (DON) confirmed that nursing staff are required to record the output when the Foley catheter is emptied. Despite this requirement, there were numerous undocumented outputs across several days in January, February, and March 2024. No facility policy was provided that addressed the documentation of urinary catheter output, indicating a lapse in adherence to the resident's care plan and proper documentation practices.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. According to the CDC's guidelines, antibiotic stewardship is crucial to optimize infection treatment and reduce adverse events. However, the facility's Infection Surveillance program from June 2023 through April 2024 showed multiple instances of 'N/A' documentation under criteria met for residents admitted from the hospital on antibiotics, indicating a lack of proper review and adherence to protocols. For Resident 159, the medical records revealed that the resident was prescribed Amoxicillin and Doxycycline for a productive cough associated with COVID-19, despite no documented justification for the antibiotics. The resident's progress notes indicated stable vital signs and no respiratory distress, yet antibiotics were administered from January 8th to January 15th, 2024. Similarly, Resident 160 was prescribed Cipro for a urinary tract infection based on symptoms like nausea and a positive dipstick test. However, the urine culture showed no growth, and the symptoms did not meet the criteria for a UTI, indicating inappropriate antibiotic use. Interviews with the facility's Infection Control Preventionist (ICP) revealed that the facility did not review antibiotics prescribed at the hospital, leading to 'N/A' documentation. The ICP could not provide an explanation or documentation for the antibiotic administration for Resident 159 and only provided a physician's note and culture results for Resident 160. This lack of proper review and documentation highlights the facility's failure to adhere to antibiotic stewardship protocols, potentially affecting multiple residents prescribed antibiotics during their inpatient care.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,130 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Novi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fox Run Village | 1.1 mi | ★★★★★ | 0 | 0 |
| Novi Lakes Health Campus | 2 mi | ★★★★★ | 0 | 0 |
| Marvin & Betty Danto Health Care Center | 3.2 mi | ★★★★★ | 6 | 0 |
| Notting Hill Of West Bloomfield | 3.6 mi | ★★★★★ | 23 | 0 |
| West Bloomfield Health And Rehabilitation Center | 3.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.