Below 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 Wellbridge Of Novi during CMS and state inspections, most recent first.
A resident with severe arthritis and cognitive decline, requiring 1:1 feeding assistance and two-person transfers, was left unattended with a meal tray out of reach. The resident fell from bed while attempting to access the tray, sustained a femur fracture, and experienced a significant delay in receiving diagnostic x-rays. The care plan lacked clear instructions for required assistance, and staff did not provide the ordered supervision at the time of the incident.
A resident with multiple cardiac and respiratory conditions did not receive newly ordered Lasix and duoneb treatments as directed by the provider, resulting in a delay of over a week before the correct medication regimen was implemented. The unit manager could not provide an explanation or documentation for the delay or errors in order entry.
A resident with a history of heart failure and other significant conditions experienced a delay in receiving a STAT chest x-ray as ordered by a provider. The order was not entered or completed for over a week due to a breakdown in the process for implementing provider orders, with no further explanation or documentation provided for the delay.
A resident with a recent joint replacement and previously intact cognition experienced a significant decline, including persistent vomiting, elevated BP, and decreased responsiveness. Despite clear signs of deterioration, LPNs and other staff did not consistently monitor or document the resident's condition, and physician notification was delayed. Staff reported being told by supervisors not to transfer the resident to the hospital, resulting in a 12-hour delay before the resident was sent to the ED, where an acute stroke was diagnosed and the resident later died.
A resident with bipolar disorder was admitted following a psychiatric hospitalization with specific physician orders for Lithium dosing. The facility failed to accurately reconcile and implement these orders, resulting in the resident not receiving the prescribed morning dose and being given an extended release formulation not specified in the hospital discharge summary. This led to increased psychiatric symptoms, including agitation, combativeness, and behavioral disturbances.
A resident with bipolar disorder did not receive the correct Lithium dosage as specified in hospital discharge instructions, resulting in ongoing behavioral disturbances. Despite multiple staff and pharmacy reviews, the medication discrepancy was not corrected, and the facility's medication reconciliation policy was not effectively followed.
A resident with a legal guardian was discharged from the facility against medical advice without the guardian's involvement. The resident, diagnosed with conditions including heart failure and cognitive deficits, left with a friend after becoming agitated. The facility failed to notify the guardian, despite records indicating the resident's guardianship status. The oversight was acknowledged by the facility administrator.
A resident with severe cognitive impairments and multiple medical conditions experienced several falls at the facility due to inadequate supervision and lack of specific safety interventions. Despite being identified as a high fall risk, the resident's care plan was not updated to reflect their needs, resulting in injuries and hospitalization.
Failure to Provide Required Supervision and Timely Care After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe rheumatoid arthritis, osteoarthritis, morbid obesity, and a recent decline in cognition was left unattended with a meal tray placed out of reach. The resident had documented needs for 1:1 feeding assistance due to their inability to feed themselves and significant mobility limitations, including a requirement for two-person assistance with transfers and being non-ambulatory. Despite these documented needs and orders, the resident was left alone in their room, sitting on the side of the bed, and attempted to reach for their meal tray, resulting in a fall from the bed. Following the fall, the resident complained of pain in the left leg, but there was a delay in obtaining diagnostic x-rays. Although a STAT x-ray was ordered the day after the fall, the imaging was not completed until approximately 30 hours after the incident. The x-ray revealed an acute comminuted fracture of the left distal femur, which required hospitalization and surgery. The resident subsequently died from complications related to the fracture. Interviews with facility staff and review of the resident's care plan and medical record revealed that the required 1:1 feeding assistance was not provided at the time of the incident. The care plan and Kardex lacked specific instructions regarding bed mobility and 1:1 assistance, and staff confirmed that no one was present to assist the resident with eating when the fall occurred. Facility policies on fall risk management and meal assistance were not followed, as interventions to prevent falls and ensure safe feeding were not implemented according to the resident's assessed needs.
Failure to Timely Implement Provider Orders for Medication and Treatment
Penalty
Summary
A resident with a history of acute on chronic diastolic congestive heart failure, edema, paroxysmal atrial fibrillation, and acute embolism and thrombosis of the lower extremities was re-admitted to the facility. The resident experienced chest pain, generalized pain, weakness, fatigue, and symptoms suggestive of a urinary tract infection and shortness of breath. Following a provider assessment, new orders were given, including an extra 20 mg of Lasix to be administered daily for three days starting immediately, a chest x-ray, urinalysis, and duoneb nebulizer treatments four times daily. The facility failed to implement the provider's orders as directed. The extra 20 mg of Lasix was not administered on the day it was ordered, and the duoneb nebulizer treatment was initially ordered three times daily instead of four. These orders were not correctly implemented until more than a week later. When questioned, the unit manager was unable to provide an explanation or documentation for the delay and incorrect implementation of the provider's orders.
Delay in STAT Chest X-ray Order and Completion
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a STAT (immediate) chest x-ray was ordered and completed as directed by a physician assistant for a resident with a history of acute on chronic diastolic heart failure, edema, paroxysmal atrial fibrillation, and acute embolism and thrombosis of the lower extremities. The resident was re-admitted with these diagnoses and was noted to have intact cognition. During a physician assessment, the resident reported increased weakness, fatigue, joint pain, dysuria, urinary urgency and frequency, and shortness of breath. The assessment included diminished breath sounds with crackles, trace bilateral lower extremity edema, and a plan to check a STAT chest x-ray due to suspected decompensated congestive heart failure. Despite the provider's documented plan for an immediate chest x-ray, a review of the physician orders revealed that the order for the STAT chest x-ray was not implemented until more than a week later. Interviews with the unit nurse manager indicated that the responsibility for entering new orders typically fell to the floor nurse or unit manager, but in this case, the order was not entered promptly, possibly due to a failure in the electronic medical system notification process. No further explanation or documentation was provided for the delay in implementing the STAT chest x-ray order.
Failure to Assess, Monitor, and Escalate Care for Resident with Change in Condition
Penalty
Summary
A facility failed to adequately assess and monitor a resident who experienced a significant change in condition, specifically a decline in responsiveness and the inability to take medications. The resident, who had recently undergone joint replacement surgery and was previously alert and mostly independent, began exhibiting symptoms such as persistent vomiting, elevated blood pressure, decreased responsiveness, and generalized weakness. Despite these changes, there was a lack of thorough documentation and monitoring, with gaps in vital sign recordings and insufficient progress notes during critical periods. Nursing staff noted the resident's altered mental status and inability to eat or drink, but did not consistently escalate the situation or ensure timely physician notification as the resident's condition worsened. Multiple staff members, including LPNs and a unit manager, were aware of the resident's deteriorating state. Both day and night shift nurses expressed concern and advocated for the resident to be transferred to a higher level of care, but reported being told by supervisors and management that they could not send the resident to the hospital. The unit manager and other leadership staff did not promptly assess the resident in person despite requests from nursing staff. There was also a failure to notify the physician of the resident's continued decline and omitted medication doses, and the physician was not made aware of the full extent of the resident's unresponsiveness until the following day. The resident remained unresponsive and without adequate monitoring or intervention for approximately 12 hours before being transferred to the hospital, where they were diagnosed with an acute stroke and subsequently died. Interviews with staff revealed confusion and lack of clarity regarding escalation protocols, as well as concerns about administrative interference with clinical decision-making. Documentation was inconsistent, and some assessments were not recorded in the medical record. The deficiency resulted in a significant delay in identifying and treating a critical medical emergency.
Removal Plan
- Resident 802 no longer resides at the facility.
- A one-time audit was completed for nurses notes and change of conditions to ensure appropriate MD notification and follow-up was completed.
- Licensed Nurses were re-educated on the change of condition policy, including appropriate assessment, and timely notification of the physician to prevent serious injury, harm, and or death.
- The facility nurse leadership team did a one-time visual assessment of all current residents to ensure no change in condition is noted and required physician notification is completed.
- The policy on change in condition was reviewed and deemed appropriate.
- DON/designee will review 5 charts weekly to ensure appropriate MD notification and change of conditions have been completed.
- Audits will be forwarded to QAPI committee for review and recommendations.
Failure to Reconcile and Implement Admission Physician Orders
Penalty
Summary
The facility failed to accurately reconcile and implement physician's orders for a resident upon admission, specifically regarding the administration of Lithium for bipolar disorder. The hospital discharge summary provided clear instructions to continue both a 300 mg morning dose and a 600 mg evening dose of Lithium, but the facility only ordered and administered a 300 mg extended release dose at bedtime. There was no order for the required 300 mg morning dose, and the resident did not receive the evening dose on the day of admission due to the medication not being available. The hospital discharge instructions also did not specify the use of an extended release formulation, yet this was what was ordered and given by the facility. As a result of these discrepancies, the resident exhibited increased psychiatric symptoms during their stay, including agitation, throwing objects, combativeness, yelling, and difficulty cooperating with care. The resident's medical history included bipolar disorder and a recent psychiatric hospitalization where a new medication regimen was initiated. The facility's failure to follow the hospital's discharge orders led to the resident not receiving the prescribed medication regimen, which coincided with the onset of behavioral disturbances and other symptoms such as slurred speech and difficulty swallowing.
Failure to Accurately Implement Hospital Discharge Medication Orders
Penalty
Summary
A deficiency occurred when a resident with bipolar disorder did not receive the correct dose of Lithium as specified in the hospital discharge instructions upon admission. The resident exhibited significant behavioral disturbances, including confusion, agitation, aggression, and disrupted sleep, which were documented by staff over several days. Despite these ongoing behaviors, there was no change to the resident's Lithium order, even after a pharmacy recommendation highlighted a discrepancy between the hospital discharge instructions and the medication being administered. The physician reviewed the resident and her medications but did not note the behavioral issues or adjust the Lithium dosage. Interviews with facility staff revealed that the process for entering and verifying admission orders involved both floor nurses and unit managers, with a second check for accuracy. However, the error in the Lithium order was not identified or corrected by nursing, the unit managers, or pharmacy. The DON acknowledged the mistake and stated that the orders should have been entered accurately, but no justification was provided for the failure to implement the correct Lithium order. The facility's policy on medication reconciliation requires careful review and resolution of discrepancies, but this process was not effectively followed in this case.
Failure to Involve Legal Guardian in Resident Discharge
Penalty
Summary
The facility failed to involve a court-appointed legal guardian in the discharge process for a resident, resulting in the resident signing themselves out of the facility against medical advice without the guardian's knowledge. The resident, who had diagnoses including adult failure to thrive, cognitive communication deficit, and heart failure, was initially admitted with a legal guardian as indicated by hospital documents and a court order. Despite this, the resident was allowed to leave the facility with a friend after becoming agitated and expressing a desire to go home, without the facility notifying the legal guardian or involving them in the discharge planning process. The facility's records, including a PASARR form, indicated the resident had a public guardian and a history of major depression and psychosis. However, the facility did not consult the guardian before the resident's discharge. The legal guardian was not informed until after the resident was readmitted to the facility. The facility administrator acknowledged the oversight, noting that there was insufficient information in the records to identify the resident's legal guardian at the time of discharge.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement appropriate interventions and provide adequate supervision to prevent falls and injuries for a resident with severe cognitive impairments and communication deficits. The resident, who had multiple medical conditions including respiratory failure, heart failure, and severe cognitive impairments, experienced several falls during their stay at the facility. Despite being identified as a high fall risk, the resident's care plan lacked specific safety interventions tailored to their cognitive and functional impairments. The facility's records indicate that the resident had multiple unwitnessed falls, resulting in injuries such as skin tears, lacerations, and ultimately a hip fracture that required hospitalization and surgery. The facility's documentation and staff interviews revealed that the resident's fall risk assessments and care plans were not adequately updated to reflect the increased risk and incidents of falls. The resident's care plan included general interventions such as administering medications and encouraging bed rest after therapy but did not address the resident's specific needs for increased supervision and safety measures. Despite the resident's repeated attempts to ambulate unassisted and their combative behavior, the facility did not implement additional fall prevention measures or provide one-on-one supervision. Interviews with staff and the Director of Nursing (DON) indicated that the facility's protocol for high fall risk residents included measures like locking wheelchair brakes and using low beds and fall mats. However, these interventions were not effectively applied to the resident in question. The facility's failure to conduct thorough follow-up and root cause analysis after each fall, and to implement appropriate and timely interventions, contributed to the resident's continued falls and eventual decline in condition, leading to their hospitalization and subsequent death.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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) |
|---|---|---|---|---|
| Novi Lakes Health Campus | 3.4 mi | ★★★★★ | 0 | 0 |
| The Manor Of Novi | 3.5 mi | ★★★★★ | 22 | 0 |
| Northville Manor | 3.8 mi | ★★★★★ | 0 | 0 |
| Fox Run Village | 4.1 mi | ★★★★★ | 0 | 0 |
| Maple Manor Rehab Center Of Novi Inc | 4.2 mi | ★★★★★ | 2 | 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.