Cycle 1
Health 2025-05-08 · Fire 2025-05-08
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Novi, MI
Novi Lakes Health Campus
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
41795 W 12 Mile Rd, Novi, MI
(248) 449-1655
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2016-12-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.80
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.46
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.51
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,033
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.75% · Performance 24.71% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.63
Baseline 9.19% · Performance 7.04% · Measure score 4.63 · Achievement 2.67 · Improvement 4.63
Total nurse turnover
4.62
Baseline 46.55% · Performance 44.78% · Measure score 4.62 · Achievement 4.62 · Improvement 0.32
Adjusted total nurse staffing
0.72
Baseline 3 hours · Performance 3.28 hours · Measure score 0.72 · Achievement 0.72 · Improvement 0.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.93% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 357 · Observed rate 13.17% · Lower 95% interval 9.74% |
| Discharge to community | 64.54% |
50.57%
14 pts better
|
Better than the National Rate · Eligible stays 352 · Observed rate 58.52% · Lower 95% interval 58.84% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.98% |
95.27%
1.3 pts worse
|
Numerator 203 · Denominator 216 |
| Falls with major injury | 0.93% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 216 |
| Discharge self-care score | 63.5% |
53.69%
9.8 pts better
|
Numerator 87 · Denominator 137 |
| Discharge mobility score | 59.12% |
50.94%
8.2 pts better
|
Numerator 81 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 215 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.04% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 220 · Observed rate 7.27% · Lower 95% interval 4.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 65.41% |
42%
23.4 pts better
|
Numerator 87 · Denominator 133 |
| Discharge function score | 66.42% |
56.45%
10 pts better
|
Numerator 91 · Denominator 137 |
| Transfer of health information to provider | 98.55% |
95.95%
2.6 pts better
|
Numerator 68 · Denominator 69 |
| Transfer of health information to patient | 97.69% |
96.28%
1.4 pts better
|
Numerator 127 · Denominator 130 |
| Resident COVID-19 vaccinations up to date | 30.63% |
25.2%
5.4 pts better
|
Numerator 34 · Denominator 111 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
95.0%
3.5 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.1%
3.1 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.1%
4.1 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.5%
3.6 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
19.6%
2.9 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
16.5%
0.9 pts better
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.4% |
11.7%
5.7 pts worse
|
14.9%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.9%
0.5 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.9% |
20.4%
5.5 pts worse
|
19.8%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.9% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
5.6%
4.6 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
82.8%
16.5 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.6% · Q3 99.2% · Q4 99.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
11.5%
6.3 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 5.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 1.1% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
79.5%
19.7 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.8% |
24.2%
9.6 pts worse
|
23.9%
9.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.8% · Observed 34.2% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-17 · Fire 2024-04-17
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-04 · Fire 2023-05-04
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-13
E · Potential for more than minimal harm
2025-05-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-16
F · Potential for more than minimal harm
2025-05-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-04
E · Potential for more than minimal harm
2025-05-08
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-06-04
E · Potential for more than minimal harm
2025-05-08
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-06-04
E · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-08
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-06-04
F · Potential for more than minimal harm
2024-04-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-21
E · Potential for more than minimal harm
2024-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-17
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-01-30
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-02-13
D · Potential for more than minimal harm
2023-11-15
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-11-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-29
G · Actual harm
2023-05-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-05-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-05-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-05-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-17
Penalties and ownership
What sits behind the stars
Ownership
Trilogy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Barney, Leigh
Corporate Officer · Individual
Bryant, William
Corporate Officer · Individual
Bufford, Randall
Corporate Officer · Individual
Conner, Gregory
Corporate Officer · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
W-2 Managing Employee · Individual
Davis, David
Corporate Officer · Individual
Fightmaster, Lisa
W-2 Managing Employee · Individual
Gahc3 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Gahc4 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Mehaffey, Todd
Corporate Officer · Individual
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Pietrowski, Cristina
Corporate Officer · Individual
Prosky, Danny
Corporate Officer · Individual
Reardon, Timothy
Operational/Managerial Control · Individual
Regions Bank
5% Or Greater Mortgage Interest · Organization
Streiff, Mathieu
Corporate Officer · Individual
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Holdings Nt-Hci, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Trilogy Real Estate Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Reit Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Fox Run Village
Novi, MI
5-star overall rating with 4-star inspections with $13,748 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
The Manor of Novi
Novi, MI
2-star overall rating with 2-star inspections with $67,496 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Maple Manor Rehab Center of Novi Inc
Novi, MI
4-star overall rating with 3-star inspections with 9 recent health deficiencies
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