Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Orion Nursing Center during CMS and state inspections, most recent first.
Failure to Timely Update Fall Plans and Complete Post-Fall Reviews: The facility did not timely implement or revise fall care plans and interventions, and it did not complete required post-fall reviews and fall risk assessments for multiple residents with repeated falls. One resident with Alzheimer’s disease, COPD, and a history of falls sustained a head strike with bruising and possible rib injury, yet the fall was not documented as reviewed by the IDT and the care plan was not modified. Other residents with repeated falls and conditions such as orthostatic hypotension, weakness, and poor balance also had delayed fall interventions and missing post-fall assessments.
Two residents experienced significant delays in care due to inadequate staffing, including one who was left on a commode for an extended period and another who fell and fractured a wrist after attempting self-care. Staff reported that aide and nurse coverage was insufficient for the number and acuity of residents, leading to late medication administration, delayed toileting, and unmet care needs. Facility records showed staffing was based on census rather than acuity, despite policy statements to the contrary.
Three residents experienced undignified treatment, including being rushed off the toilet by a CNA, being accused of privacy violations during a phone call, and being moved to another room while upset and crying due to a C. diff diagnosis. In each case, staff failed to provide appropriate support or follow-up, and social work was not involved when residents were distressed.
A resident with a legal guardian and multiple medical conditions was allowed to leave with an unknown individual without guardian consent, proper documentation, or verification of the person's identity. Staff failed to notice the resident's absence for over a day, and the resident was later found hospitalized for alcoholic ketosis and lactic acidosis after walking in extreme heat. The facility did not follow its own LOA policy or ensure the resident's safety.
A resident with a history of alcohol dependence and a legal guardian left the facility unsupervised, consumed alcohol, and was hospitalized for alcohol withdrawal and related complications. Facility records and staff interviews confirmed there was no care plan or interventions in place to address the resident's substance use disorder, and no policy was provided regarding management of such cases.
A resident with dementia and a history of frequent falls was left unsupervised on the toilet despite being identified as high risk and requiring staff attendance per her care plan and the facility's fall prevention protocol. After the resident activated her call light, an LPN assisted her onto the toilet but left her unattended, and a CNA did not respond to the call light. The resident fell, sustaining a severe head injury and hip fracture, and later died from her injuries. The facility's investigation confirmed that staff failed to follow required supervision protocols.
A resident with impaired cognition fell from a mechanical lift during a transfer, resulting in severe injuries, including fractures and a brain bleed. The CNA conducting the transfer used a housekeeper as a spotter instead of another trained caregiver, and the lift was missing a crucial safety clip. The facility's policy required two people for transfers but did not specify that both needed to be trained caregivers, leading to a misunderstanding.
A resident with a history of heart disease and TIA suffered first-degree burns after a dietary aide handed them a hot coffee without proper containment, leading to a spill. The resident's functional decline affected their grip, causing the spill. The aide did not follow the facility's protocol for serving hot beverages.
Failure to Timely Update Fall Plans and Complete Post-Fall Reviews
Penalty
Summary
The facility failed to ensure that fall care plans and fall interventions were timely implemented, reviewed, and revised, and it did not follow its Falls Risk Management policy requiring fall review by the interdisciplinary team and post-fall fall risk assessments. The cited deficiency involved multiple residents with documented falls, including residents with cognitive impairment, orthostatic hypotension, weakness, poor balance, and a history of falls. The survey findings showed that fall-related documentation, care plan updates, and post-fall assessments were missing or delayed after several incidents. One resident with Alzheimer’s disease, COPD, and a history of falls had a fall on 2/21/26 after getting up and walking in the room, losing balance, and striking the head on a wheelchair. The resident reported pain and requested evaluation due to prior fractures and sprains, and later a physician documented rib cage pain and multiple bruises to the face, arms, and humerus with concern for a possible rib fracture. The care plan for risk for falls was not modified after the fall, and there was no documentation that the interdisciplinary team reviewed the fall or fall interventions. The Administrator stated there were no fall incident reports available for this resident. Another resident had multiple falls on 1/1/26, 2/15/26, 3/4/26, 3/25/26, and 4/16/26, yet fall interventions were not timely implemented. A care plan for actual falls and poor balance was initiated on 3/4/26, but interventions were not implemented until 4/21/26, five days after the 4/16/26 fall. A separate fall risk care plan for weakness was initiated on 2/6/26, more than a month after the 1/1/26 fall, and no fall care plans were in place before that despite a moderate fall risk score and history of falls. The record also showed no post-fall fall risk assessments for the documented falls. A third resident fell on 2/19/26 while trying to plug in a phone, sustaining a skin tear to the left elbow, and the record likewise showed no post-fall fall risk assessment for that event.
Failure to Provide Adequate Nursing Staff Results in Delayed Care and Resident Harm
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple incidents involving insufficient aide coverage, delayed response to call lights, and unmet care needs. On one occasion, a resident with range of motion impairment and requiring assistance for toileting was left on a bedside commode for approximately an hour and a half, despite activating the call light and eventually using a cell phone to call for help. Staff interviews confirmed that only one aide was available for an entire floor of residents during the shift in question, resulting in significant delays in care and frustration among residents. Staff also reported that management was notified of the staffing shortages, but the situation persisted, with aides and nurses expressing concerns about the unsafe staff-to-resident ratios and the inability to provide timely care. Another resident experienced a fall resulting in a wrist fracture after attempting to remove a wet incontinence pad from their bed due to delayed assistance. Documentation and staff interviews indicated that there were only two aides on the floor during the night shift prior to the fall, and the post-fall review noted the absence of a midnight aide to perform regular checks and changes. The resident, who was cognitively intact, reported pain and was sent to the emergency department for evaluation. Staff further described ongoing issues with inadequate staffing, including the removal of housekeeping staff from non-care tasks such as meal tray delivery, which increased the burden on nursing aides and contributed to delays in resident care and meal service. Review of facility records, including staffing schedules, assignment sheets, and the facility assessment, revealed that staffing decisions were primarily based on census numbers rather than resident acuity. Although the facility's policy stated that staffing should account for acuity and care needs, there was no evidence that acuity was factored into actual staffing assignments. Staff consistently reported that the number of aides and nurses was insufficient to meet the needs of residents with higher acuity, leading to late medication administration, delayed toileting and hygiene care, and increased risk of adverse events.
Failure to Promote Resident Dignity During Care and Room Transfers
Penalty
Summary
The facility failed to provide an environment that promoted and enhanced residents' dignity for three residents. One resident reported that a CNA rushed them off the toilet while they were attempting to have a bowel movement, using a raised voice and displaying a negative attitude. The resident described feeling belittled and scared, and stated that no one followed up with them about the incident. Review of the resident's care plan confirmed they required one-person assistance with toileting and transfers, and documentation showed the resident was cognitively intact. There was no evidence in the medical record of any nursing, social services, or staff documentation or follow-up regarding the incident. Another resident described an incident where a CNA abruptly interrupted their phone conversation, accused them of violating privacy rights, and stated they would not provide care for the rest of the night. The resident became upset and cried, and two nurses intervened, apologized, and reassured the resident. The resident's sister came to the facility to provide support. The resident reported that the CNA had not provided care to them since the incident. The resident was alert and oriented at the time of the interview. A third resident was moved to another room after being diagnosed with C. diff. The resident did not want to move and became visibly upset, crying and yelling during the transfer. The administrator and supervisor insisted on the move, and maintenance staff moved the resident in her bed while other staff observed. The resident reported feeling humiliated and stated that staff did not treat her with respect and dignity. Interviews with staff confirmed that social work was not involved prior to the move, and the infection control nurse later stated that the move was not handled appropriately from an infection control perspective. The resident remained upset until she was allowed to return to her original room.
Failure to Protect Resident with Legal Guardian During Leave of Absence
Penalty
Summary
A resident with a history of hemiplegia, alcohol dependence, diabetes, and schizoaffective disorder, who had a legal guardian, was allowed to leave the facility on a leave of absence (LOA) with an unknown individual without the required consent from the legal guardian. The staff failed to verify the identity of the person signing the resident out, did not obtain a contact number, and did not confirm the destination or expected return time. The resident was signed out with only an illegible signature and insufficient information in the LOA logbook. The facility's policy required that residents with legal guardians could only leave with the guardian or those approved by the guardian, but this was not followed. After the resident left, multiple shifts of nursing staff failed to notice or report that the resident had not returned for approximately 30 hours. There was a lack of communication between shifts, and no progress notes were made regarding the resident's absence during this period. The absence was only discovered when a nurse on a later shift realized the resident was missing, at which point attempts were made to contact the family, guardian, and police. The legal guardian was not notified prior to the resident's departure, nor was she aware of the hospitalization that resulted from the incident. The resident was eventually found hospitalized for alcoholic ketosis and lactic acidosis after being exposed to high temperatures and consuming alcohol. The resident reported being left without a ride, walking in extreme heat, and ultimately requiring emergency medical attention. Interviews with staff revealed a lack of awareness of the facility's LOA policy, insufficient documentation, and failure to assess whether the resident could safely leave with the individual. The facility's investigation confirmed that staff did not follow required procedures for residents with legal guardians and did not ensure the resident's safety during the LOA.
Failure to Assess and Address Substance Abuse Disorder in Resident
Penalty
Summary
The facility failed to ensure that a resident with a known substance abuse disorder received appropriate behavioral health care and services. The resident, who had a diagnosis of alcohol dependence with withdrawal and a legal guardian for medical decisions, was able to leave the facility on a leave of absence without proper oversight. The resident was missing for approximately 1.5 days and was later found at a hospital, where he was treated for alcoholic ketosis, withdrawal, dehydration, and lactic acidosis after consuming alcohol during his absence. Review of the resident's clinical records and hospital documentation confirmed recent alcohol consumption, despite previous psychiatric notes stating the resident did not currently drink alcohol. The hospital records detailed the resident's symptoms, including chest pain, generalized pain, vomiting, and heat exposure, and confirmed treatment for alcohol withdrawal and related complications. The resident's care plan and social services progress notes did not address his substance use disorder, and there was no documentation of interventions or discussions regarding his alcohol abuse. Interviews with facility staff, including the social worker and administrator, confirmed that no care plan or interventions were in place to address the resident's alcohol abuse disorder. Additionally, the facility was unable to provide a policy regarding the management of residents with substance abuse disorders when requested by surveyors. These findings indicate a lack of assessment and intervention for the resident's behavioral health needs related to substance abuse.
Failure to Provide Required Supervision During Toileting Results in Resident Fall and Death
Penalty
Summary
A deficiency occurred when a resident with a history of falls, dementia, and impaired decision-making capacity was left unsupervised on the toilet, contrary to her individualized care plan and the facility's 'Falling Star' protocol. The resident had experienced multiple falls in the months and days leading up to the incident, including several within a 24-hour period, and had been identified as high risk for falls. Her care plan required staff to remain in attendance while toileting, either in the bathroom or just outside the door, as part of the facility's fall prevention measures. On the day of the incident, the resident activated her call light, and an LPN assisted her onto the toilet. The LPN then left the resident unattended, reportedly to request assistance from a CNA, but camera footage did not confirm any interaction between the LPN and the CNA. The CNA assigned to the hallway did not respond to the call light, citing other responsibilities and a lack of direct assignment to the resident. The resident remained unsupervised for approximately eight minutes before staff responded, during which time she fell and sustained a severe head injury and hip fracture. The resident was found on the bathroom floor with a large hematoma on her left temple and reported hip pain. She was assessed by nursing staff and a nurse practitioner, and subsequently transferred to the hospital, where she was diagnosed with an acute subdural hematoma and an acute intertrochanteric fracture of the left femur. The resident's condition deteriorated, and she died shortly after the incident. The facility's investigation confirmed that staff were aware of the resident's high fall risk and the requirement for supervision during toileting, but failed to follow the established protocol.
Plan Of Correction
deficiency = "1. Resident R801 no longer resides at the facility.\n\n2. A facility-wide audit was completed by the Director of Nursing on 6/24/25 to identify other residents assessed to be high risk for fall (i.e., enrolled in the Falling Star Program). Plans of care for these residents were reviewed to ensure toileting and supervision interventions were in place. All residents enrolled in the Falling Star Program were issued a visual alert (star) on their room door and care card was updated. Residents requiring supervision while toileting were cross-checked for compliance with protocol that prohibits staff from leaving residents unattended.\n\n3. The policy "The Falling Star Program" was reviewed and updated to reflect the implementation of a visual alert on the hallway door.\n\n4. Re-Education of all staff:\na. As of 6/26/25, all licensed staff nurses and CNAs were re-educated on:\n• The facility's Falling Star Protocol and expectations.\n• Supervision requirements during toileting.\n• The process of direct communication during handoffs.\nb. Staff were tested post training to ensure comprehension. Competency validation included return demonstrations of supervised toileting protocol.\n\nc. Education with Licensed Nurses: Licensed nurses were instructed not to delegate supervision of high-risk residents without confirmed verbal acknowledgment from receiving staff.\n\n5. Monitor plan to Ensure Ongoing Compliance:" planOfCorrection = ""
Resident Falls Due to Improper Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, resulting in the resident falling and sustaining multiple severe injuries. The resident, who had moderately impaired cognition and was dependent on staff for transfers, was being moved by a CNA using a mechanical lift. The CNA attempted the transfer without the assistance of another trained caregiver, instead asking a housekeeper to act as a spotter. During the transfer, the resident fell from the sling due to a missing safety clip on the lift, leading to significant injuries including fractures and a brain bleed. The investigation revealed that the mechanical lift used in the transfer was missing a safety clip, which was crucial for securing the sling. The CNA involved in the incident was aware of the missing clip but proceeded with the transfer, believing it would not affect the safety of the operation. The facility's policy required two people for such transfers, but it did not specify that both needed to be trained caregivers, leading to a misunderstanding by the CNA. Interviews with staff indicated that the CNA did not seek appropriate assistance from other nursing staff, as they were occupied with other duties. The facility's investigation determined that the missing safety clip was a pivotal factor in the resident's fall. The incident highlighted a lack of clear communication and understanding regarding the importance of safety clips and the requirement for trained personnel during mechanical lift transfers.
Failure to Safely Serve Hot Beverage Results in Resident Burns
Penalty
Summary
The facility failed to safely serve a hot beverage to a resident, resulting in first-degree burns on their abdomen and chest. The incident occurred when a dietary aide handed a cup of hot coffee to the resident without proper containment, leading to the coffee spilling onto the resident. The resident, who was cognitively intact with a BIMS score of 15/15, had a history of heart disease and TIA with intracranial injury, which contributed to functional decline and weakness in fine motor skills. This condition affected the resident's ability to grip the cup properly, resulting in the spill. The dietary aide confirmed that they did not follow the facility's protocol for serving hot beverages, which required the coffee to be covered. The aide acknowledged that the resident did not have a firm grip on the cup handle, leading to the spill. The incident was documented in a Facility Reported Incident, and a post-incident medical assessment diagnosed the resident with first-degree burns, requiring treatment with Silvadene cream.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lake Orion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Villa At Silverbell Estates | 4.7 mi | ★★★★★ | 13 | 0 |
| Wellbridge Of Clarkston | 7.7 mi | ★★★★★ | 2 | 0 |
| Villa At Pine Place | 7.8 mi | ★★★★★ | 14 | 0 |
| The Springs At Rochester Hills Rehab And Nursing C | 8 mi | ★★★★★ | 27 | 0 |
| Bellbrook | 9.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.