Novi Lakes Health Campus

Observed Resident’s A, B and C to have assistive devices affixed to their bed frames. The facility lacked physician’s orders for the devices directing their purpose and authorization for use. [REPEAT VIOLATION ESTABLISHED]

Review of resident service plans revealed that Resident A, B and C’s plans were void of any information pertaining to the bedside assistive devices and lacked instruction to staff on the monitoring of the residents while the devices are in use. [REPEAT VIOLATION ESTABLISHED]

Resident C missed a scheduled dose of cyclobenzaprine on 4/1/25, 4/2/25, 4/3/25, 4/5/25, 4/7/25, 4/8/25 and 4/10/25. Staff documented the reason for the missed doses as “drug/item unavailable”, despite staff documenting the medication was administered between doses it was listed as not in the building. When questioned, Employee 1 reported “We do have a back up system that we can utilize and cyclobenzaprine is in the system. The nurses are able to pull from it- med techs are not. It could be the nurse pulled the medication from the back up system, or it could be a charting error.”

Resident F missed a scheduled dose of omega-3 on 4/1/25, 4/2/25, 4/3/25, 4/4/25, 4/7/25, 4/12/25, 4/13/25, 4/19/25, 4/20/25, 4/21/25, 4/22/25, 4/23/25, 4/25/25, 4/26/25, 4/27/25, 5/3/25 and 5/4/25. Staff documented the reason for the missed doses as “drug/item unavailable”, despite staff documenting the medication was administered between doses it was listed as not in the building. When questioned, Employee 1 reported: The residents girlfriend does supply this medication so we do rely on her to supply the facility with this med. This medication cannot be pulled from our back up system as we do not have it available. It could be an error- or possibly the staff that said it was not available were unaware of where it is kept in the medication cart. I will ensure everyone is aware of where it is kept.

Resident G missed one or more scheduled doses of oxycodone on 4/3/25, 4/13/25 and 4/14/25. Staff documented the reason for the missed doses as “drug/item unavailable”, despite staff documenting the medication was administered between doses it was listed as not in the building. When questioned, Employee 1 reported: The residents girlfriend does supply this medication so we do rely on her to supply the facility with this med. This medication cannot be pulled from our back up system as we do not have it available. It could be an error- or possibly the staff that said it was not available were unaware of where it is kept in the medication cart. I will ensure everyone is aware of where it is kept.

Observed that each MAR showed habitual practices of staff not documenting the medication pass at the time medications are administered and also not listing the time the medication was administered. For example, staff repeatedly would note “charted late” or “charted late given on time” but not identify what time the medication pass occurred. For Resident B, this occurred with one or more medications on the following dates: 4/3/25, 4/4/25, 4/5/25, 4/6/25, 4/9/25, 4/11/25, 4/12/25, 4/15/25, 4/16/25, 4/17/25, 4/18/25, 4/24/25, 4/26/25, 4/28/25, 4/29/25, 4/30/25, 5/2/25, 5/3/25 and 5/5/25.