9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Southfield, MI
2-star overall rating with 1-star inspections with $71,130 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
19933 West Thirteen Mile Road, Southfield, MI
(248) 203-9000
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
172
Certified beds
Average residents
158
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Optalis Health & Rehabilitation
Operator or chain grouping
Approved since
1997-11-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 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
RN hours / resident day
0.51
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.52
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.02
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.20
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.85
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Program rank
5,574
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9893
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.88
Baseline 21.10% · Performance 21.03% · Measure score 0.88 · Achievement 0.88 · Improvement 0
Healthcare-associated infections
7.86
Baseline 7.36% · Performance 5.49% · Measure score 7.86 · Achievement 7.86 · Improvement 7.43
Total nurse turnover
4.14
Baseline 55.25% · Performance 46.75% · Measure score 4.14 · Achievement 4.14 · Improvement 2.30
Adjusted total nurse staffing
1.40
Baseline 3.43 hours · Performance 3.47 hours · Measure score 1.40 · Achievement 1.40 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.96% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 657 · Observed rate 13.39% · Lower 95% interval 9.95% |
| Discharge to community | 62.67% |
50.57%
12.1 pts better
|
Better than the National Rate · Eligible stays 666 · Observed rate 51.5% · Lower 95% interval 58.52% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.44% |
95.27%
4.2 pts better
|
Numerator 355 · Denominator 357 |
| Falls with major injury | 0.28% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 357 |
| Discharge self-care score | 55.95% |
53.69%
2.3 pts better
|
Numerator 141 · Denominator 252 |
| Discharge mobility score | 60.71% |
50.94%
9.8 pts better
|
Numerator 153 · Denominator 252 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 7 · Denominator 357 · Adjusted rate 1.73% |
| Healthcare-associated infections requiring hospitalization | 5.49% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 403 · Observed rate 4.96% · Lower 95% interval 4.04% |
| Staff COVID-19 vaccination coverage | 3.8% |
8.2%
4.4 pts worse
|
Numerator 10 · Denominator 263 |
| Staff flu vaccination coverage | 27.39% |
42%
14.6 pts worse
|
Numerator 83 · Denominator 303 |
| Discharge function score | 57.94% |
56.45%
1.5 pts better
|
Numerator 146 · Denominator 252 |
| Transfer of health information to provider | 96.68% |
95.95%
0.7 pts better
|
Numerator 204 · Denominator 211 |
| Transfer of health information to patient | 98.08% |
96.28%
1.8 pts better
|
Numerator 102 · Denominator 104 |
| Resident COVID-19 vaccinations up to date | 25.9% |
25.2%
0.7 pts better
|
Numerator 43 · Denominator 166 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.7
0.7 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
95.0%
4.7 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.7% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
3.1%
2.8 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.4% |
4.1%
0.3 pts worse
|
11.4%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.9% · Q3 1.5% · Q4 2.9% · 4Q avg 4.4% |
| 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 · Q1 3.4% · Q2 1.5% · Q3 1.5% · Q4 1.4% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
19.6%
5.7 pts better
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 13.6% · Q3 11.9% · Q4 15.1% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
16.5%
5.9 pts better
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 11.5% · Q3 10.5% · Q4 11.5% · 4Q avg 10.6% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.4% |
13.9%
4.5 pts better
|
16.3%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.3% · Q3 15.4% · Q4 11.6% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
11.7%
3.8 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.7% · Q3 6.8% · Q4 12.1% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 1.3% · Q4 2.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.3% |
20.4%
5.1 pts better
|
19.8%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 10.2% · Q3 20.1% · Q4 17.7% · 4Q avg 15.3% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.6%
1.8 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.5% · Q3 2.9% · Q4 4.1% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
82.8%
17 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 99.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
11.5%
5.9 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 4.9% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.5% · Q3 0.5% · Q4 0.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
79.5%
16.9 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.7% |
24.2%
4.5 pts worse
|
23.9%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 29.4% · Expected 24.4% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (10 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-10-02
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-10-02
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-02
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-02
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-10-02
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-16
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-07
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-07
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-10-07
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-10-07
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-10-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-30
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-30
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-03-11
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-02-06
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-30
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-30
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-09-17
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-17
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-17
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2024-09-17
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-09-17
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-09-17
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-09-17
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-17
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-17
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-11
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-06-14
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 2024-06-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-02
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-02
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-02
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-04-02
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-27
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-02
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-04-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-15
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-08
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-12-08
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-12-08
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-28
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-07-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-28
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-28
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-07-28
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 2023-07-28
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-07-28
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-28
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-28
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-07-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-28
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-28
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-28
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 2023-07-28
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-07-28
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-07-28
Penalties and ownership
Fine · fine $28,815
Fine
Fine · fine $42,315
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Mortgage Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Beverly Hills, MI
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $339,637 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Southfield, MI
2-star overall rating with 2-star inspections with $47,320 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Southfield, MI
1-star overall rating with 1-star inspections with Special Focus status with $414,510 in total fines with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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