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 Oakpointe Senior Care And Rehab Center during CMS and state inspections, most recent first.
Staff did not follow Enhanced Barrier Precautions when an LPN provided PEG tube care to a resident without donning a gown, despite clear signage and available PPE. Additionally, three residents receiving oxygen therapy had their nasal cannula tubing improperly stored on chairs or wheelchairs rather than in plastic bags as required by facility policy. Both staff and the DON acknowledged these lapses in infection control protocols.
A staff member violated a resident's privacy by posting a video of the resident, who has dementia and behavioral health diagnoses, on a personal social media account without consent. The video showed the resident in a common area, and the incident was discovered after the family notified administration. The staff member admitted to the action, which was confirmed by facility investigation.
A resident with type 2 diabetes continued to have blood sugar checks four times daily for 51 days despite pharmacy recommendations to discontinue the regimen due to normal readings. The facility failed to follow up with the physician, resulting in unnecessary monitoring.
The facility failed to follow professional standards during medication administration for three residents, leading to potential errors. An RN was unsure of the intended recipient of medications she did not prepare, leaving the cart unlocked and the computer screen open. Another resident's MAR was incorrectly signed by an LPN who did not administer the medications. Additionally, medications were crushed without a physician's order, violating facility policy.
A resident with a history of stroke and multiple sclerosis experienced edema due to the facility's failure to implement a physician's order for compression stockings. Despite the order being in place for months, staff did not apply the stockings, and the resident's care plan lacked interventions for edema. Interviews revealed that staff were unaware of the order, leading to the resident's condition worsening.
A facility failed to adhere to restorative therapy recommendations for a resident with hemiplegia, risking contractures. The resident required range of motion exercises twice daily, but the facility did not document these activities, as confirmed by the DON. The facility's policy mandates consistent care to prevent decline, but it was not followed.
A facility failed to secure smoking materials and conduct a smoking assessment for a resident identified as a current smoker. A cigarette lighter was found in the resident's room, contrary to the facility's policy that such items be stored at the front desk. Interviews revealed inconsistencies in policy adherence, as the resident did not have a smoking assessment despite being identified as a smoker in admission records.
The facility did not post nurse staffing information for 98 residents and visitors. Observations showed the staffing board in the lobby had smudged information, making it unreadable. The board was not updated over several days, and the Administrator confirmed it was meant for staffing information. Supervisor O, responsible for updates, admitted the board was written on with the wrong ink, preventing changes, and failed to inform the Administrator or DON.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.69% error rate. Errors included a nurse administering two puffs of an inhaler instead of one, and another nurse preparing an incorrect dosage of Ativan, leading to a resident receiving half the prescribed dose for four consecutive doses. These actions were contrary to the facility's medication administration guidelines.
A resident with multiple diagnoses, including anxiety and depression, received only half of the prescribed Ativan dose for four consecutive administrations due to a medication error. The error was identified during a surveyor's observation, revealing that the facility's medication administration policy was not followed, resulting in the resident receiving 0.5 mg instead of the prescribed 1.0 mg.
An Environmental Services Aide in an LTC facility failed to follow infection control protocols by not performing hand hygiene after glove removal and wearing gloves in the hallway. This was observed during cleaning activities in the rooms of two residents with significant health conditions, despite the facility's policy requiring hand hygiene before and after glove use.
Failure to Follow Enhanced Barrier Precautions and Proper Oxygen Tubing Storage
Penalty
Summary
The facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) and proper use of Personal Protective Equipment (PPE) during resident care. Specifically, an LPN was observed administering a water flush through a resident's PEG tube without donning a gown, despite clear signage and availability of PPE outside the resident's room. The resident involved had multiple diagnoses, including convulsions, dementia, failure to thrive, dysphagia, and was cognitively impaired. The facility's policy required the use of gown and gloves for high-contact care activities involving medical devices, which was not followed in this instance. Both the LPN and the DON acknowledged the lapse in protocol during interviews. Additionally, the facility did not ensure proper storage of oxygen tubing for three residents receiving oxygen therapy. Observations revealed that nasal cannula tubing was left exposed on chairs or wheelchairs and not stored in plastic bags when not in use, as required by facility policy. Staff interviews confirmed awareness of the correct procedure, and the DON stated that oxygen tubing should be stored in a plastic bag when not in use. The residents involved had diagnoses such as obstructive sleep apnea, chronic respiratory failure, asthma, and other chronic conditions, and were cognitively intact according to their assessments.
Resident Privacy Breach via Social Media Post
Penalty
Summary
A staff member at the facility failed to maintain a resident's right to privacy and confidentiality by posting a video of the resident on a personal social media account without the consent of the resident or their legal guardian. The incident was discovered when the resident's family notified the Nursing Home Administrator that the video, which showed the resident seated in a wheelchair in a common area and yelling out, had been temporarily posted online before being deleted. The staff member involved, a newly hired CNA, admitted to recording and posting the video, stating they were unaware it was being uploaded to social media. The resident involved had a history of mood disorder, psychotic disorder with delusions, and dementia with behaviors, and was admitted with multiple diagnoses including altered mental status. At the time of the incident, the resident was fully clothed, seated alone, and showed no signs of injury. The facility's investigation confirmed the privacy violation, and the resident was subsequently sent to the hospital for evaluation at the family's request.
Failure to Act on Pharmacy Recommendations for Insulin Regimen
Penalty
Summary
The facility failed to act upon pharmacy recommendations in a timely manner for a resident with type 2 diabetes, resulting in unnecessary monitoring. The resident had been prescribed Novolog insulin per sliding scale four times daily, but the pharmacy recommended discontinuing this regimen due to consistently normal blood sugar readings and a normal A1C level. Despite this recommendation, the facility did not follow up with the physician, and the resident continued to undergo blood sugar checks four times a day for 51 days without any insulin administration. The facility's policy required that pharmacy recommendations be communicated and acted upon in a timely manner, with a system in place to ensure that observations and recommendations were documented and addressed. However, the facility did not adhere to this policy, as there was no documented follow-up with the physician regarding the pharmacy's recommendation. This oversight led to continued unnecessary blood sugar monitoring for the resident, contrary to the pharmacy's advice.
Medication Administration Errors and Protocol Breaches
Penalty
Summary
The facility failed to adhere to professional standards of practice during medication administration for three residents, leading to potential medication errors. For one resident, a registered nurse (RN) was observed with a medication cup containing six unidentified pills and two Lasix pills without a resident's name on the packaging. The RN admitted she did not prepare the medications herself and was unsure which resident they were intended for. The medication cart was left unlocked, and the computer screen displaying resident health information was left open. The RN could not confirm if the resident had received their morning medications, and the pills were eventually disposed of without being administered. Another resident's medication administration record (MAR) was signed by a licensed practical nurse (LPN) who did not administer the medications, contrary to the standard practice that requires the administering nurse to sign the MAR. Additionally, a third resident's medications were crushed and mixed with yogurt without a physician's order, as confirmed by the electronic health record. The facility's policy requires specific orders for crushing medications, which were not present in this case. These actions demonstrate a failure to follow the facility's medication administration guidelines, resulting in potential medication errors.
Failure to Implement Compression Stockings Order
Penalty
Summary
The facility failed to clarify and implement a physician's order for compression stockings for a resident, leading to the resident experiencing edema and potential cardiovascular compromise. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis following a stroke, multiple sclerosis, and an overactive bladder, was observed with swollen feet and expressed concerns about the lack of intervention despite reporting the issue to staff. The resident's medical records indicated a physician's order for compression socks dated several months prior, but there was no documentation of the socks being applied, nor were there any care plans or interventions addressing the resident's edema. During interviews, staff members, including a CNA and an RN, acknowledged the oversight. The CNA was unaware of the order for compression socks and stated that nonskid socks were being used instead. The RN confirmed that the order for compression socks was not followed through, as it was not entered into the computer system, and no special instructions were provided. This lack of action and communication resulted in the resident not receiving the prescribed treatment, contributing to the observed swelling and discomfort.
Failure to Follow Restorative Therapy Recommendations
Penalty
Summary
The facility failed to follow restorative therapy recommendations for a resident, identified as R89, who was at risk of developing contractures due to hemiplegia/hemiparesis following a cerebral infarction. During an observation, R89 was seen sitting in a geri chair, unable to move the left side of the body, and a family member expressed the need for continued therapy. The resident's medical record indicated a requirement for passive, active, and assisted active range of motion exercises twice daily, as per a restorative nursing referral. However, the Kardex did not document specific needs or instructions related to these therapy recommendations. Interviews with the Therapy Manager and Director of Nursing revealed that the facility did not document the performance of the recommended range of motion exercises. The Director of Nursing confirmed the absence of evidence that these exercises were being conducted as per the therapy recommendations. The facility's policy on restorative programs emphasized the need for a comprehensive assessment and consistent care to prevent the decline of a resident's abilities unless clinically unavoidable. However, the policy was not adhered to, as there was no documentation of the resident's participation or progress in the restorative program.
Failure to Secure Smoking Materials and Conduct Smoking Assessment
Penalty
Summary
The facility failed to secure smoking materials and complete a smoking assessment for a resident, identified as R82, who was reviewed for smoking safety, accidents, and hazards. During an observation, a cigarette lighter was found on R82's bedside table, which the resident reported was given by a family member and usually kept in a purse. Despite being identified as a current smoker in nursing admission assessments, R82 did not have a smoking assessment completed. The Life Enrichment Director confirmed that cigarettes and lighters should be stored at the front desk, indicating a lapse in following the facility's policy. Interviews with the Nursing Home Administrator and Social Worker revealed inconsistencies in the facility's adherence to its Safe Smoking policy. The NHA initially reported that R82 did not have a smoking assessment because the resident does not smoke, contradicting the admission assessment that identified R82 as a current smoker. The Social Worker confirmed that all residents should have a smoking assessment upon admission, which was not completed for R82. The facility's policy requires a smoking assessment before a resident can smoke independently and mandates that smoking materials be kept in a designated area, which was not followed in this case.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information for all 98 residents and visitors entering the facility. Observations on multiple occasions revealed that the nurse staffing board, located behind the front receptionist desk in the lobby area, displayed smudged out numbers and information related to nurse staffing, making it unreadable. The board was observed in this condition on 6/11/24 at 9:30 A.M., 2:30 P.M., and 4:30 P.M., and remained unchanged on 6/12/24 at 12:30 P.M. and 4:00 P.M. On 6/13/24 at 10:00 A.M., the board still had not been updated. At 11:00 A.M., the Administrator confirmed that the board in the front lobby was intended for posting nurse staffing information and identified Supervisor O as responsible for updating it. Supervisor O admitted that the board had been written on with the wrong kind of ink/marker, preventing updates, and acknowledged that the information had not been updated since the weekend but failed to inform the Administrator or Director of Nursing.
Medication Administration Errors Result in 7.69% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 7.69% error rate during a medication administration observation. Two medication errors were identified among 26 opportunities for error. The first error involved a registered nurse administering two puffs of Breo-Ellipta inhaler to a resident, contrary to the physician's order and Medication Administration Record (MAR) which prescribed only one puff. This discrepancy was observed during the morning medication round. The second error involved a licensed practical nurse in training, who, under supervision, prepared and administered an incorrect dosage of Ativan to another resident. The nurse initially prepared one 0.5 mg pill instead of the prescribed two 0.5 mg pills for the resident's morning dose. Upon review by the surveyor, it was discovered that the resident had been receiving only half of the prescribed dose for four consecutive doses. The facility's Medication Administration General Guidelines Policy requires verification of medication orders against the MAR before administration, which was not adhered to in these instances.
Medication Error: Resident Received Half Prescribed Dose
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the resident receiving only half of the prescribed dose of anti-anxiety medication for four consecutive doses. The resident, who had multiple diagnoses including malignant neoplasm of the brain, generalized anxiety disorder, and major depressive disorder, was prescribed Ativan 1.0 mg to be taken twice daily. However, due to an oversight, the resident was administered only 0.5 mg of Ativan for four consecutive doses. The error was discovered during a medication administration observation when a surveyor prompted the nurses to review the prescribed dosage. It was confirmed that the resident had been receiving only half of the prescribed dosage for several administrations. The facility's policy requires that medication orders be reviewed and confirmed prior to administration, but this protocol was not followed, leading to the medication error. The Clinical Corporate Director acknowledged the error and confirmed the responsibility of the nursing staff to administer the correct dosage.
Infection Control Deficiency: Improper Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection control standards regarding glove use and hand hygiene, as observed in the actions of an Environmental Services Aide. During the survey, it was noted that the aide cleaned the rooms of two residents, one with dementia and diabetes and the other with diabetes, COPD, and prostate cancer, without performing hand hygiene after removing gloves. The aide was observed exiting the room, removing gloves, and then putting on new gloves without washing hands, which is against the facility's hand hygiene policy. The aide also wore gloves in the hallway, which is not permitted according to the facility's infection control protocols. Despite being educated on proper glove use and hand hygiene, the aide was unaware of the requirement to perform hand hygiene after glove removal. The facility's policy clearly states that hand hygiene should be performed before and after applying gloves, yet this was not followed, leading to a potential risk of cross-contamination and infection among the residents.
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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 Detroit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westwood Nursing Center | 1.3 mi | ★★★★★ | 21 | 0 |
| Hartford Nursing & Rehabilitation Center | 1.3 mi | ★★★★★ | 23 | 0 |
| The Orchards At Northwest | 1.6 mi | ★★★★★ | 22 | 0 |
| Sheffield Manor Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 15 | 0 |
| Oakland Nursing Center | 2.5 mi | ★★★★★ | 0 | 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.