Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Novi Lakes Health Campus during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was given metoprolol despite physician orders to hold the medication for low systolic blood pressure. The medication was administered on two occasions when the resident's blood pressure was below the specified threshold, and the resident subsequently required intervention for low blood pressure. The DON confirmed the medication should have been held according to the order.
The facility failed to provide readily accessible Medication Regimen Review (MMR) documentation within the EMR for five residents during an investigation into unnecessary medications. Additionally, a resident was observed with a power cord wrapped around her fingers, and her activity records were not found within the EHR. The Administrator acknowledged the issue and mentioned a potential pilot program to address it.
The facility failed to ensure proper infection control protocols, including EBP, hand hygiene during medication pass, and cleanliness of medical equipment for multiple residents. Several LPNs did not perform proper hand hygiene, and there was a lack of clear policy on cleaning medical equipment, leading to unsanitary conditions.
The facility failed to provide SNFABN forms detailing estimated charges of continued services for three residents, as required by policy. Interviews and record reviews revealed that the responsible staff were unable to provide the necessary forms, and the Administrator confirmed the documents could not be located.
A facility failed to provide facial hair removal for a dependent resident who expressed a desire for it. Despite the resident's care plan indicating that facial shaving should be offered, staff did not take action, and there was no documentation of facial hair removal in the resident's shower schedule. Interviews with staff confirmed awareness of the issue but no action was taken.
The facility failed to provide competency documentation for three CRCAs, resulting in the potential for staff incompetency and/or harm to residents' well-being. The NHA was unable to retrieve the necessary documentation and confirmed the absence of an acting staff educator and a policy for regular in-service education.
The facility failed to document annual performance reviews and the required 12-hour in-service education for three CRCAs. The NHA was unable to retrieve the necessary documentation and confirmed the absence of a staff educator and a specific policy for regular in-service education.
The facility failed to ensure that resident food items stored in the [NAME] Parlor refrigerator were labeled, dated, and discarded when expired. Several undated or expired food items were found, and the refrigerator temperature had not been logged. The Dietary Manager admitted the refrigerator had not been checked during his absence.
Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A facility failed to administer blood pressure medication according to a physician's order for one resident following their re-admission after a hospital stay. The resident had multiple diagnoses, including chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, chronic kidney disease, diabetes, and anxiety disorder. The physician's order for metoprolol specified that the medication should be held if the resident's systolic blood pressure (SBP) was less than 110 or heart rate (HR) was less than 60. Despite this, the medication was administered on two occasions when the resident's SBP was documented as 101/56 and 101/59, both below the specified threshold. A progress note indicated that after one of these administrations, the resident's blood pressure remained low, with a last reading of 85/57, prompting notification of the nurse practitioner and a new order for a one-time dose of Midodrine to address the low blood pressure. The facility's Director of Nursing confirmed in an interview that the metoprolol should have been held per the instructions. The facility's policy on medication administration requires medications to be given in accordance with prescriber orders, which was not followed in this instance.
Plan Of Correction
F684 SS=D Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Element 1 Resident #901 no longer remains within the facility. Nurse "A" that completed medication errors received 1:1 education on following parameters noted within blood pressure medication orders. Element 2 All current residents receiving blood pressure medications that have parameters have the potential to be affected by this citation. These residents have had a medication administration record reviewed for the last 7 days to ensure blood pressure medications were administered appropriately. Element 3 Actively scheduled floor nurses have been educated on medication administration policy and specifically following parameters noted within blood pressure medication order. Actively scheduled floor nurses that have not completed this education by the date of compliance will be in-serviced prior to their next shift. Element 4 DHS/Designee will audit 5 residents' administration records that have blood pressure medications with parameters to ensure the assigned nurse followed the parameters listed within the medication order x4 weeks. Findings/trends will be submitted to the QAPI committee for review and recommendation on continued audits. Executive Director is responsible for obtaining compliance. Element 5 July 3rd, 2025
Failure to Provide Accessible Medical Records
Penalty
Summary
The facility failed to provide readily accessible Medication Regimen Review (MMR) documentation within the Electronic Medical Record (EMR) for five residents (R17, R27, R33, R150, R15) during an investigation into unnecessary medications. On 4/16/24, the EMR was reviewed for these residents, and MMR documentation was not readily accessible. The Director of Nursing (DON) confirmed that MMR documentation is not located in the EMR but is uploaded into a different software program, requiring designated staff members to retrieve it. This lack of accessibility hinders the ability of all disciplines to obtain necessary information regarding the residents' conditions, care, and services. Additionally, on 04/15/24, a resident (R251) was observed lying in bed with the power cord for the overhead light wrapped tightly around her fingers, appearing anxious and restless. A family member reported that the resident often fixates on the cord/light and is difficult to redirect. On 04/16/24, an attempt to review the resident's activity records within the EHR was unsuccessful, as no records were found. The Life Enrichment Director reported that a change of condition assessment had been completed for the resident, but those records were documented in a separate EHR system, to which the survey team was not given access. The Administrator acknowledged that the facility's documents were not all located in the residents' electronic records and mentioned that a sister facility was working on a pilot program to address this issue.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices, including enhanced barrier precautions (EBP), hand hygiene during medication pass, and proper cleanliness of medical equipment for multiple residents. For instance, R150, who required EBP due to a dialysis catheter, had no precaution signs on their door on multiple occasions. Similarly, R44, who had a feeding tube, initially had no EBP notification on their door until it was later posted by the Director of Nursing (DON). R18, who was dependent on a PEG tube, had visibly soiled tube feeding equipment, and there was no EBP signage or PPE visible in or around the room until much later. Additionally, R20, who had a Foley catheter, also lacked EBP documentation on their door until an order was entered later in the day. During medication administration, several Licensed Practical Nurses (LPNs) failed to perform proper hand hygiene. LPN C did not perform hand hygiene before administering medications to R202, LPN D did not perform hand hygiene before administering medications to R203, and LPN E picked up a paper towel off the floor and proceeded to administer medications to R204 without performing hand hygiene. The DON confirmed that hand washing should have been performed prior to administering medications. The facility also lacked a clear policy on cleaning medical equipment, as evidenced by the soiled condition of R18's tube feeding equipment. When questioned, the assigned Registered Nurse (RN) G incorrectly stated that housekeeping was responsible for cleaning the equipment. The DON confirmed that the equipment was not sanitary and needed cleaning. The Nursing Home Administrator (NHA) later confirmed that there was no specific policy for cleaning medical equipment, indicating a gap in infection control practices.
Failure to Provide SNFABN Forms
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) detailing estimated charges of continued services for three residents. The deficiency was identified during a review of 88 residents who were discharged from Medicare-covered Part A stay within a specified period. The review focused on three residents who either discharged from the facility or decided to remain. The facility was unable to provide the requested SNFABN forms for these residents, indicating a failure to notify them of their discontinuation of service coverage and their rights to proceed. An interview with the Social Service staff revealed that they were responsible for issuing SNFABN forms but were newly employed and unable to provide the forms for the specified residents. The Administrator also confirmed the inability to locate the requested documents. The facility's policy requires the issuance of a Notice of Medicare Non-Coverage (NOMNC) two calendar days prior to the actual discharge from Medicare, but this procedure was not followed for the residents in question.
Failure to Provide Facial Hair Removal for Dependent Resident
Penalty
Summary
The facility failed to ensure a dependent resident was provided with unwanted facial hair removal. On two separate occasions, the resident was observed with long facial hair and expressed a desire for it to be removed. The resident reported that they had not had their facial hair removed in a long time and were only receiving bed baths. The resident's care plan indicated that facial shaving should be offered on shower days, as needed, or upon request. However, there was no documentation of facial hair removal in the resident's shower schedule, and the last recorded shower was several days prior to the observations. Interviews with facility staff, including the CNA assigned to the resident and the Director of Nursing, revealed that the staff were aware of the resident's long facial hair but did not take action to remove it. The CNA stated that the resident did not ask for the hair to be removed, and the DON confirmed that the resident should have had their facial hair removed according to the care plan. The facility's policy on ADL documentation guidelines was reviewed, which stated that ADL services should be conducted and documented by the CNA each shift at the point of care or as reasonably possible after care.
Failure to Provide Competency Documentation for CRCAs
Penalty
Summary
The facility failed to provide competency documentation with proficiency of skills and techniques necessary to care and assure resident safety for three Certified Resident Care Associates/Certified Nursing Assistants (CRCA/CNA J, K, M) out of five reviewed. This deficiency was identified during an interview and record review process. On 4/16/2024, the Nursing Home Administrator (NHA) was unable to provide the requested documentation for CRCA J, K, and M, citing a delay due to a support call placed to the Internal Technology (IT) department. By 4/17/2024, the NHA confirmed that the retrieval of the competency documentation was unsuccessful and revealed that the facility did not have an acting staff educator or a policy regarding regular in-service education for CRCAs, relying solely on regulations instead.
Failure to Document Annual Reviews and In-Service Education for CRCAs
Penalty
Summary
The facility failed to provide documentation of annual performance reviews and the required minimum 12-hour in-service education competencies for three Certified Resident Care Associates/Certified Nursing Assistants (CRCA/CNA J, K, M) out of five reviewed. This deficiency was identified during an interview and record review process. The Nursing Home Administrator (NHA) was unable to retrieve the necessary documentation for these CRCAs, despite placing a support call to the Internal Technology (IT) department. The NHA confirmed that the facility could not verify if the annual performance reviews and in-service education competencies were completed for these staff members. Additionally, the NHA revealed that there is no acting staff educator for the facility and that the facility does not have a policy regarding regular in-service education for CRCAs, instead following general regulations.
Failure to Label, Date, and Discard Expired Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that resident food items stored in the [NAME] Parlor refrigerator were labeled, dated, and discarded when expired. During an observation at 9:30 AM, several food items were found undated or past their use-by dates, including a container of green pudding, a sub sandwich, multiple brown bags labeled 'leftover meal,' a Pyrex container of meat and vegetables, a half-eaten cheeseburger, a container of pasta, and a plastic bag of unknown food. Additionally, the refrigerator temperature had not been logged since [DATE]. When queried, the Dietary Manager (DM) admitted responsibility for monitoring the refrigerator but noted it had not been checked during his absence the previous week. The facility's policy requires food brought in by family members, friends, or guests to be properly labeled, date-marked, stored, and discarded according to the facility's procedures, which was not adhered to in this instance.
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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) |
|---|---|---|---|---|
| Fox Run Village | 1.1 mi | ★★★★★ | 0 | 0 |
| The Manor Of Novi | 1.9 mi | ★★★★★ | 22 | 0 |
| Maple Manor Rehab Center Of Novi Inc | 2 mi | ★★★★★ | 2 | 0 |
| Wellbridge Of Novi | 3.4 mi | ★★★★★ | 3 | 0 |
| Marvin & Betty Danto Health Care Center | 4.1 mi | ★★★★★ | 6 | 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.