Cycle 1
Health 2024-11-19 · Fire 2024-11-19
14 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Southfield, MI
The Lakeland Center
2-star overall rating with 1-star inspections with $189,324 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
26900 Franklin Road, Southfield, MI
(248) 350-8070
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
Facility snapshot
Beds
91
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Optalis Health & Rehabilitation
Operator or chain grouping
Approved since
1999-03-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.34
Registered nurse staffing
LPN hours / resident day
1.60
Licensed practical nurse staffing
Aide hours / resident day
2.01
Nurse aide staffing
Weekend hours
3.58
Weekend nurse staffing
RN turnover
79%
Annual RN turnover
Total nurse turnover
60%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
4.1%
3.2 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.5%
1 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.3% |
19.6%
10.3 pts better
|
19.6%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
16.5%
2.8 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.3% |
13.9%
7.6 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
11.7%
6.6 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.1% |
20.4%
8.3 pts better
|
19.8%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.6%
0.4 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
82.8%
11.4 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
11.5%
5.3 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.3%
0.4 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.5% |
79.5%
13 pts better
|
79.7%
12.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
24.2%
1.2 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-31 · Fire 2024-01-31
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-31 · Fire 2023-03-31
29 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (7 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-19
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-12-05
E · Potential for more than minimal harm
2024-11-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-05
F · Potential for more than minimal harm
2024-01-31
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-01-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-23
F · Potential for more than minimal harm
2024-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-01-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-01-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-23
E · Potential for more than minimal harm
2023-03-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-04-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-08-29
G · Actual harm
2025-07-02
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 2025-07-17
D · Potential for more than minimal harm
2025-07-02
F690 · Quality of Life and Care Deficiencies
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 2025-07-21
F · Potential for more than minimal harm
2025-04-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-23
F · Potential for more than minimal harm
2024-11-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-05
F · Potential for more than minimal harm
2024-11-19
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 2024-12-05
E · Potential for more than minimal harm
2024-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-19
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-12-05
D · Potential for more than minimal harm
2024-11-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-19
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 2024-12-05
D · Potential for more than minimal harm
2024-11-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-19
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 2024-12-05
D · Potential for more than minimal harm
2024-07-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-02
J · Immediate jeopardy
2024-05-29
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 2024-05-29
F · Potential for more than minimal harm
2024-01-31
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-01-31
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-31
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-01-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-19
K · Immediate jeopardy
2023-07-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-07-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-07-27
K · Immediate jeopardy
2023-03-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-24
F · Potential for more than minimal harm
2023-03-31
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-31
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 2023-04-26
F · Potential for more than minimal harm
2023-03-31
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-31
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-04-26
F · Potential for more than minimal harm
2023-03-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-31
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-31
F584 · Resident Rights Deficiencies
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 2023-04-26
E · Potential for more than minimal harm
2023-03-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-31
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-03-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-25
E · Potential for more than minimal harm
2023-03-31
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 2023-04-26
E · Potential for more than minimal harm
2023-03-31
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-31
F578 · Resident Rights Deficiencies
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 2023-04-26
D · Potential for more than minimal harm
2023-03-31
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-31
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 2023-04-26
D · Potential for more than minimal harm
2023-03-31
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 2023-04-26
D · Potential for more than minimal harm
2023-03-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-31
F688 · Quality of Life and Care Deficiencies
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 2023-04-26
D · Potential for more than minimal harm
2023-03-31
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 2023-04-26
D · Potential for more than minimal harm
2023-03-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-03-31
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 2023-04-26
D · Potential for more than minimal harm
2023-03-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-26
Penalties and ownership
What sits behind the stars
$15,926
2024-05-29
Fine
Fine · fine $15,926
Fine
$15,877
2023-07-06
Fine
Fine · fine $15,877
Fine
$50,178
2023-07-06
Fine
Fine · fine $50,178
Fine
$107,343
2023-03-31
Fine
Fine · fine $107,343
Fine
$0
2023-03-31
Payment Denial
Payment Denial · denial start 2023-04-27 · 28 days
28 day denial
Ownership
Reh 1 Corporation
5% Or Greater Direct Ownership Interest · Organization
Pomeroy Delaware Investments #2, LLC
5% Or Greater Indirect Ownership Interest · Organization
Patel, Pinal
5% Or Greater Indirect Ownership Interest · Individual
Shah, Nayana
5% Or Greater Indirect Ownership Interest · Individual
Enid Barden Trust
5% Or Greater Indirect Ownership Interest · Organization
Enid Barden Trust
Limited Partnership Interest · Organization
Optum Management Solutions. Inc
Operational/Managerial Control · Organization
Patel, Pinal
Limited Partnership Interest · Individual
Pomeroy Delaware Investments #2, LLC
Limited Partnership Interest · Organization
Reh 1 Corporation
General Partnership Interest · Organization
Shah, Nayana
Limited Partnership Interest · Individual
Nearby options
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#2
Evergreen Health and Rehabilitation Center
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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
#3
Beaconshire Nursing Centre
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1-star overall rating with 2-star inspections with $33,243 in total fines with 10 recent health deficiencies with 26 fire-safety deficiencies in the latest cycle
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