The Lakeland Center

In the surveyor’s words

From the most serious findings on record at The Lakeland Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 6, 2023

  This citation pertains to Intake Number(s): MI00137119. This citation contains two Deficient Practice Statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from deprivation of goods and services by staff for sixteen (R's 707, 708, 709, 710, 711, 712, 713, 714, 705, 715, 704, 716, 717, 718, 719, 722) of 24 residents reviewed for neglect. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when these residents did not have an assigned licensed or registered nurse for 6 hours and 22 minutes (12:38 AM to 7:00 AM on 5/18/23) and did not receive multiple physician ordered medications needed to treat medical conditions, such as, insulin, blood pressure, seizure, pain, Parkinson,… […]

• Immediate jeopardy, patternF600Mar 31, 2023

  This citation pertains to Intake Number(s): MI00131469, MI00131551, MI00131999, and MI00131552. Based on observation, interview, and record review, the facility failed to protect residents' rights to be free from deprivation of goods and services by staff for nine (R28, R57, R14, R36, R45, R24, R68, R60, and R7) of 13 residents reviewed for neglect. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when these residents were not assigned a licensed or registered nurse for 12 hours (7:00 PM on 9/22/22 until 7:00 AM on 9/23/22) and did not receive multiple physician ordered medications needed to treat medical conditions, such as, pain, cardiac disease, blood clots, psychiatric disorders, diabetes, and post kidney transplant therapy; did not provide wound… […]

• Immediate jeopardy, isolatedF689May 29, 2024

  This citation has two Deficient Practice Statements (DPS). DPS #1 This citation pertains to intakes MI00144702, MI00144797, and MI00144715. Based on observation, interview and record review, the facility failed to provide adequate supervision and implement elopement policies for one (R500) of four residents reviewed for elopement, resulting in a severely cognitively impaired resident being let out of a secured door to the patio by an unknown staff member, unsupervised and was found approximately 36 hours later, about five miles away from the facility. This deficient practice resulted in the likelihood for serious harm, injury, impairment, or death. Findings include: The Immediate Jeopardy (IJ) began on 5/26/24. […]

• Immediate jeopardy, isolatedF689Sep 14, 2022

  This citation pertains to intake #MI 900. Based on observation, interview, and record review the facility failed to develop and implement interventions and ensure adequate supervision to prevent the elopement of one of two residents reviewed for elopement (R701), resulting in immediate jeopordy when on 8/27/22 at 8:27 PM R701 eloped from the facility and was returned to the facility by police at 2:40 AM. Review of the facility investigation file reveale a document that read, .RESIDENT INTERVIEW/SUMMARY OF FINDING OR ALLEGATION .Resident was observed leaving the facility on camera and a staff member behind him within 30 seconds .CONTRIBUTING FACTORS AND INTERVENTIONS: .2. […]

• Actual harm, isolatedF689Jul 2, 2025

  This citation relates to Intake 1302878. Based on observation, interview, and record review, the facility failed to ensure proper positioning to prevent an avoidable fall with injury for one Resident (R703) of one resident reviewed for falls, which resulted in actual harm, with increased pain, emergent care, hospitalization, and fearfulness. Findings include: Review of a complaint intake received on 6/20/25 revealed R703 resided at the nursing facility with a diagnosis of stroke and limited range of motion in their extremities. The complaint showed R703 had a fall at night on 6/19/25 after warning the aide not to turn her, as she felt like there was not enough room on the bed. The aide reportedly proceeded to turn R703, and R703 hit their head on the floor. […]