Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Oakland Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment sustained a foot fracture after a fall, but the facility failed to document attempts to secure podiatry services or the family's decision to decline emergency care. The care plan was not updated to reflect the resident's non-weight bearing status, and the EMR lacked necessary documentation, leading to a deficiency in maintaining accurate medical records.
The facility did not consistently post daily nurse staffing information, affecting all 19 residents. Observations showed outdated postings and missing night shift data. A review from December 2024 to February 2025 revealed numerous instances of missing postings. The Administrator acknowledged the issue.
The facility failed to maintain sanitary conditions in the kitchen, with observations of grease and cobwebs on vent shielding, dried splatter on the oven, and water droplets in stacked pans. The dish machine did not reach the required temperature, and temperature logs were not maintained, potentially affecting all residents consuming food from the kitchen.
The facility failed to ensure proper infection control practices regarding TBP, linen storage, and PPE disposal. Observations showed PPE caddies without TBP signage, exposed clean linens, and improper disposal of used PPE. Orders for TBP lacked specific precautions, and facility policies on infection control were not followed.
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.45%. On two occasions, a nurse administered incorrect medications to residents, including giving cetrizine instead of loratidine and failing to administer Miralax at the scheduled time. The errors were confirmed through record reviews and reconciliations with physician's orders.
A resident's DNR wishes were not honored due to incorrect documentation in the EMR, leading to unnecessary resuscitation measures. The facility failed to communicate the correct advance directives to EMS, resulting in the resident being treated as a full code.
Failure to Document Podiatry Referral and Family Decisions
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation in the medical record for a resident following a change in condition. The resident, who had severe cognitive impairment, sustained a fragmented fracture of their right foot after rolling out of bed. Despite a referral to podiatry services, the resident was not seen by a podiatrist during their stay. The care plan was not updated to reflect the resident's non-weight bearing status after the fall, as directed by the physician. The resident's electronic medical record (EMR) lacked documentation of attempts to have the resident seen by a podiatrist or any explanation for why the resident was not seen. The Director of Nursing (DON) reported attempts to arrange a podiatry visit, but these were not documented in the EMR. Additionally, the family reportedly declined an emergency room visit, but this was also not documented. The physician confirmed the fracture was minor and did not require urgent podiatry consultation, but the lack of documentation regarding the family's decision and the facility's attempts to secure podiatry services was noted as a concern. The resident was diagnosed with COVID-19 during their stay, which may have impeded their ability to receive outside podiatry services. The facility's policy on documentation requires that all relevant information be recorded, including assessment findings and patient and family education. However, the EMR did not reflect the necessary documentation, leading to a deficiency in maintaining accurate and complete medical records.
Plan Of Correction
R 301 did not experience any adverse reaction to the alleged deficient practice. R301 discharged home with her daughters on 2/28/25 in stable condition. All residents have a potential to be affected by the alleged deficient practice. Policy and Procedure for the Documentation has been reviewed by the DON/LNHA and deemed appropriate. Physician staff Nursing team will be re-educated in regards to the Documentation Policy & Procedure with emphasis on: • Documenting time frame for consults. (Physician) • Documenting communication and education provided to resident/family. (Physician and Nursing) Administrator/DON or designee will conduct Physician and Nursing documentation audits to ensure compliance 3x/week for one month. Findings will be presented to QAPI Monthly x3 and PRN. Administrator/DON will be responsible for sustained compliance.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information as required, which had the potential to affect all 19 residents residing in the facility. During an observation on February 12, 2025, it was noted that the Daily Nursing Staff Posting at the nursing station was outdated, displaying information from two days prior, and lacked data for the night shift. A review of records from December 2024 through February 2025 revealed multiple instances where the night shift data was missing, and several dates where no staffing information was posted at all. The Administrator acknowledged these deficiencies and indicated that staff needed to be inserviced.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an initial tour with the Registered Dietician (RD). The vent shielding was found to contain grease and cobwebs, and the top and side of the oven had dried splatter. Additionally, the drying rack of stacked pans still had water droplets inside the pans. The dish machine, which had just finished washing the morning dishes, was tested and found to have a rinse cycle temperature of only 111 degrees on the first try and 115 degrees on the second try, both below the required temperature of greater than 120 degrees. The RD indicated that the dish machine had not been set to the correct setting by a new staff member that morning, and the temperature logs revealed no temperature had been taken prior to the breakfast dishes being cleaned/rinsed. The facility's sanitation program and infection control policies were reviewed and indicated that all equipment should be thoroughly cleaned after each use and that the dishwasher should be maintained and operated per the manufacturer's directions, with temperatures recorded at each meal. The failure to adhere to these policies and maintain sanitary conditions in the kitchen had the potential to affect all residents consuming food from the kitchen.
Infection Control Deficiencies in TBP, Linen Storage, and PPE Disposal
Penalty
Summary
The facility failed to ensure appropriate infection control practices concerning transmission-based precautions (TBP), linen storage, and disposal of used personal protective equipment (PPE). Observations revealed that rooms 321, 323, 327, and 332 had over-the-door caddies containing PPE without signage indicating the type of TBP. Additionally, a linen cart in the hallway was observed multiple times with its protective cover flipped up, exposing clean linens to potential contaminants and storing items such as gloves, trash bags, and gowns on top. A small garbage can outside a room was found containing used PPE, and a housekeeper was seen exiting a TBP room into the clean hallway without doffing PPE. Orders for residents in rooms 321, 323, 327, 332, and 335 included TBP but did not specify the type of precautions required. The facility's policies on TBP and general infection prevention and control were not adhered to, as confirmed by the Infection Preventionist during an interview. The facility's policy on isolation and TBP required that the attending physician write orders for TBP, document the type of precautions in the electronic medical record, and post appropriate signage on the resident's door. The general infection prevention and control policy mandated that clean patient care supplies be stored in a designated clean area and covered to minimize recontamination. Linen was to be covered at all times before use and stored on a shelf. These policies were not followed, leading to potential contamination risks for all 20 residents in the facility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate less than five percent, resulting in a medication error rate of 6.45%. On two separate occasions, Nurse 'D' administered incorrect medications to residents. On 4/29/24, Nurse 'D' administered cetrizine 10 mg to a resident who had an order for loratidine 10 mg. The error was confirmed when the resident's physician's orders and medication stock were reviewed, revealing that the resident did not have an order for cetrizine and that loratidine was not available in their medication stock. On 5/1/24, Nurse 'D' failed to administer Miralax 17g to another resident at the scheduled time of 9:00 AM, despite confirming that all due medications had been administered. The discrepancy was identified when the resident's physician's orders were reconciled against the medications observed to be administered. The Director of Nursing confirmed that medications should be administered according to the 'Five Rights'—right resident, right medication, right dose, right route, and right time.
Failure to Honor Resident's DNR Wishes
Penalty
Summary
The facility failed to ensure that the advance directives information for a resident was correct, resulting in the resident's initial wishes of Do Not Resuscitate (DNR) not being followed. The resident, who was admitted with congestive heart failure, dyspnea, interstitial lung disease, and atrial fibrillation, was transferred to the hospital for chest pain and respiratory distress. Despite having a signed DNR form, the facility communicated to Emergency Medical Services (EMS) that the resident was a full code, leading to unnecessary full resuscitation measures, including CPR and intubation, being performed. The error was discovered when the resident's family arrived at the emergency department and informed the providers of the resident's actual DNR status. A review of the resident's clinical records revealed that the DNR order was not entered into the Electronic Medical Record (EMR) and the resident's code status was incorrectly documented as a full code. The Director of Nursing (DON) confirmed that the advance directives were not communicated correctly and that the orders in the EMR were incorrect. The attending physician indicated that nursing staff are responsible for entering orders into the computer but was unsure how they are reconciled. The facility's policies on Do Not Resuscitate and Advance Directives were not followed, leading to the failure to honor the resident's wishes.
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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 Southfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Southfield | 2 mi | ★★★★★ | 25 | 1 |
| The Villa At Great Lakes Crossing | 2.3 mi | ★★★★★ | 8 | 0 |
| Regency Heights-detroit | 2.3 mi | ★★★★★ | 0 | 0 |
| Oakpointe Senior Care And Rehab Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Hartford Nursing & Rehabilitation Center | 2.6 mi | ★★★★★ | 23 | 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.