Novi Lakes Health Campus

Inspectors wroteThis citation pertains to intake: 3073158. Based on interviews and record reviews the facility failed to timely implement appropriate treatment and interventions for pressure wounds and failed to identify and timely respond to the worsening of the wound for one (R201) of one resident reviewed for wounds. This resulted in the prompting of the family to insist on the transfer of the resident to a higher level of care and subsequently required multiple debridements and multiple Intravenous antibiotics therapy to treat the infected decubitus ulcer with an associated abscess and fat necrosis of the buttock wound and pain.

Inspectors wroteThis citation pertains to intake: 3072746. Based on interview and record reviews the facility failed to follow current standards of practice for obtaining weights for one (R202) of one resident reviewed for Nutritional concerns.

Inspectors wroteBased on interview and record review, the facility failed to implement key elements of an effective water management plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility .

Inspectors wroteBased on observation, interview and record review, the facility failed to determine self-administration of medications was safe and appropriate for three (R5, R46, R30) of four observed with medications at the bedside. Findings Include. R46 On 7/6/26 at 10:11AM, R46's bedside table was observed revealing two tubes of Vitamin A&D ointment (moisture barrier topical medication) and one tube of Calmoseptine (zinc and menthol topical medication). Record review of R46's Medication Administration Record (MAR) did not indicate Vitamin A&D and Calmospetine was ordered and no prescriber's order to self-administer. On 7/7/2026 at 8:11AM, During medication administration for R11, one tube of Vitamin A&D ointment was observed on the bedside table. Record review of R11's MAR did not indicate Vitamin A&D was ordered and no prescriber's order to self-administer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored safely, securely, and properly, in one of two medication administration carts, two of two treatment carts, and one of one medication room observed for medication storage and labeling.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean, comfortable, homelike environment for one [R69] of two residents reviewed for environment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure tube feeding automatic water flush was administered per the physician order for one [R70] of one resident reviewed for tube feeding.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's medical record was accurate and complete for one (R73) of one resident reviewed for accurate resident records.

Inspectors wroteThis citation pertains to intake #MI00153247. Based on interview and record review the facility failed to administer blood pressure medications per physician's orders for one resident, (R901) of one resident reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physician/Physician Extender progress notes were entered into the clinical record in a timely manner for four residents (R#'s 13, 29, 138, and 37 ) of four resident's reviewed for Physician/Physician Extender progress notes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the exterior dumpster area in a clean manner. This deficient practice had the potential to affect all residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices during medication administration for one (R88) of three residents observed.

Inspectors wroteBased on interview and record review, the facility failed to obtain a resident's code status in a timely manner for two residents, (R#'s 138 and 139) who were their own responsible parties, of two resident's reviewed for code status, resulting in the potential for end of life wishes not being met.

Inspectors wroteBased on interview and record review, the facility failed to provide readily accessible Medication Regimen Review (MMR) documentation within the Electronic Medical Record (EMR) to ensure the residents condition, care, and services were obtainable by all disciplines for five residents (R17, R27, R33, R150, R15, R251) of five reviewed for unnecessary medications.

Inspectors wroteR20 On 4/15/24 at 9:57 AM, R20 was observed sitting in a wheelchair, upon entering the room there was no precaution sign on the resident's door. The Resident was observed to have a foley catheter with a collection bag hanging from the underside of the wheelchair. On 4/15/24 at approximately 11 AM, there was no EBP documentation on their door. A review of R20's clinical record revealed the resident was initially admitted on [DATE] with diagnoses that included: urinary tract infection, sepsis and kidney failure. A review of Resident Progress Notes from 3/4/24 at 9:29 PM revealed that the resident had a foley catheter in place at that time. A review of R20's order history revealed an order for Enhanced Barrier Precautions entered on 4/15/24 at 3:41 PM which read in part Staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) detailing estimated charges of continued services for three residents (R26, R7, and R33) out of three sampled residents reviewed for SNF Beneficiary Protection Notification.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a dependent resident was provided unwanted facial hair removal for one (R39) of three residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on interview and record review, 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 Associate/Certified Nursing Assistants (CRCA/CNA J, K, M) out of five reviewed resulting in the potential for staff incompetency and/or harm to the residents' well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of annual performance reviews and minimum 12-hour in-service education competencies for three Certified Resident Care Associate/Certified Nursing Assistants (CRCA/CNA J, K, M) out of five reviewed resulting in the potential for staff incompetency and/or harm to the residents' well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food items stored in the [NAME] Parlor refrigerator, were labeled, dated and discarded when expired. This deficient practice had the potential to affect all residents that store food in the resident refrigerator.

Inspectors wroteThis citation pertains to intake: MI00142272. Based on interview and record review the facility failed to ensure the required documentation for a resident's transfer was documented and contained in the medical record for one (R706) of one resident reviewed for discharges and transfers.

Inspectors wroteThis citation pertains to Intake Number(s): MI00137446. Based on interview and record review, the facility failed to implement an appropriate discharge plan that included a referral to home health care (HHC) to meet the continuing needs of a resident who was discharged home for one (R803) of two residents reviewed for discharge planning.

Inspectors wroteThis citation pertains to Intake Number(s): MI00137446. Based on interview and record review, the facility failed to ensure there was a physician's order for oxygen therapy for one (R803) of one resident reviewed for respiratory care.