Inspection Reports for
Bickford of West Lansing

R 325.1922 Admission and retention of residents: the discharge notice provided to Resident A did not include specific details on the substantial risk, the discharge location, and the right to file a complaint with the Department.

R 325.1921 Governing bodies, administrators, and supervisors: the facility lacked detailed information in Resident B’s service plan on behaviors requiring medication administration or use of nonpharmaceutical interventions.

R 325.1922 Admission and retention of residents: the facility did not have an admission agreement on file for Resident A.

R 325.1922 Admission and retention of residents: Residents A, F, and G did not have tuberculosis tests within 12 months prior to admission.

R 325.1923 Employee's health: staff person 1 was not properly screened for tuberculosis within 10 days of hire and the facility did not complete the annual TB risk assessment.

R 325.1931 Employees; general provisions: care staff did not attest to applying skin prep wipes and foam dressing to Resident E’s right foot on 03/28-03/29; similar findings for Resident B.

R 325.1931 Employees; general provisions: employees SP2, SP3, and SP4 did not complete required staff training.

R 325.1932 Resident medications: staff did not initial administration of Risperidone to Resident B on 03/04/2025 at 2:00pm and 03/07/2025 at 2:00pm.

R 325.1964 Interiors: no continuous exhaust ventilation was provided in the beauty salon, soiled linen room, and janitor closets.

R 325.1976 Kitchen and dietary: items in common area refrigerators were not labeled with open and used by dates.

R 325.1976 Kitchen and dietary: multiple food items served and not eaten were not destroyed in the memory care unit and common area refrigerators.

R 325.1979 General maintenance and storage: laundry room was unlocked allowing access to janitor closet and furnace room where hazardous and toxic materials were easily accessible to cognitively impaired residents.

R 325.1932 Resident medications: Resident A did not receive medications as prescribed by the prescribing licensed health care professional.

R 325.1921 Governing bodies, administrators, and supervisors: The facility did not ensure the safety and protection of Resident A by allowing her to administer her own medications without ensuring competency.

R 325.1922 Admission and retention of residents: The facility did not have the required written statement from a licensed health care professional at the time of Resident A’s admission.

R 325.1932 Resident medications: The facility was not following Resident A’s service plan by allowing her to administer her medications.

R 325.1932 Resident medications: Staff did not document that medications were administered as prescribed, including missing documentation on multiple days.

R 325.1932 Resident medications: The facility did not appropriately contact the licensed health care professional when Resident A did not receive her prescribed medications.

R 325.1933 Personal care of residents: the facility could not demonstrate that Resident A was offered a shower at least once a week.

R 325.1931 Employees; general provisions: the facility does not have adequate staff to meet resident needs as evidenced by call light response times averaging 35 minutes, staffing below guidelines on multiple days, and insufficient caregivers for residents requiring two person assists.

R 325.192 Admission and retention of residents: service plans for Resident A and Resident D were not updated to adequately include current resident care needs.

MCL 333.20201 Policy describing rights and responsibilities of patients or residents; adoption; posting; contents; additional requirements; discharging, harassing, retaliating, or discriminating against patient exercising protected right; exercise of rights by patient's representative; informing patient or resident of policy; designation of person to exercise rights and responsibilities; additional patients' rights; definitions: Resident B’s privacy was violated when staff showed Resident B’s medication administration record to a relative.

R 325.1931 Employees; general provisions: Resident A was to be checked on nightly per service plan, but interviews revealed this was not completed by third shift staff.

R 325.1932 Resident medications: Staff incorrectly documented that medications were administered to Resident A on 03/26/2024 after Resident A was discharged on 03/22/2024.

R 325.1921 Governing bodies, administrators, and supervisors: Resident A must wait on average 21 minutes for staff assistance, resulting in not receiving required assistance such as toileting and dressing.

R 325.1921 Governing bodies, administrators, and supervisors: the facility lacked an organized program of protection for residents regarding the clinical needs of Resident C, including delayed communication with the physician and delayed antibiotic order.

R 325.1932 Resident’s medications: Resident C was prescribed Keflex antibiotic on 11/18/2023 but there was no record that this medication was administered.

R 325.1921 Governing bodies, administrators, and supervisors: the service plans for Residents C, D, and E lacked detailed information on medication administration behaviors and bedside assistive devices had no physician orders or proper service plan instructions.

R 325.1922 Admission and retention of residents: admission agreements for Residents A, B, C, D, and E were not valid due to missing or inactive signatures.

R 325.1922 Admission and retention of residents: the facility did not have tuberculosis tests within 12 months of admission for Residents A, C, and E and failed to complete an annual TB risk assessment.

R 325.1923 Employee's health: employee records lacked tuberculosis tests within 10 days of hire and before occupational exposure; the facility did not complete the annual TB risk assessment for employees.

R 325.1931 Employees; general provisions: the administrator or designees did not ensure resident competencies with the staff training program.

R 325.1964 Interiors: there was no continuous air flow in the bathroom, spa room, and janitor closet on the west side of the building.

R 325.1964 Interiors: missing ceiling tiles were observed in various laundry rooms and bathrooms.

R 325.1970 Water supply systems: the water temperature at plumbing fixtures used by residents reached only 88 degrees Fahrenheit, below the required 105 to 120 degrees.

R 325.1976 Kitchen and dietary: the dishwasher sanitized with a heat cycle but the facility had no record of testing the heat sanitation, risking resident infection.

R 325.1976 Kitchen and dietary: leftover food including ice cream, tea, and sandwiches were found in refrigerators and not discarded as required.

R 325.1968 Toilet and bathing facilities: a resident bathroom on the main level was used for storage of wheelchairs, walkers, and medical equipment, violating use restrictions.

R 325.1979 General maintenance and storage: the janitor closet in the memory care area was unlocked with a bin of dirty rags accessible to cognitively impaired residents.

R 325.1981 Disaster plans: the facility had no written disaster plans for emergencies such as fire, explosion, loss of heat, power, or water.

R 325.1970 Water supply systems: the boiler does not hold appropriate hot water temperatures which interferes with resident showers, washing of clothing and linens, and sanitization of kitchen items and dishes.

R 325.1979 General maintenance and storage: Resident A’s room was not kept clean and in good repair due to a detectable cat urine odor and cat litter scattered around the litter box in the bathroom.

325.1922 Admission and retention of residents: Resident A’s service plan was not updated to reflect that Resident A receives assistance from staff with cat care, despite being marked as independent.

R 325.1932 Resident Medications: the facility failed to complete the medication log for Resident A in September 2023.