Inspection Reports for
Gaslight Village Assisted Living & Memory Care
2625 N Adrian Hwy, Adrian, MI 49221, United States, MI, 49221
Back to Facility Profile7 Reports
Inspection Report — May 28, 2026
Renewal
Date: May 28, 2026
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The home was found in non-compliance with 3 rules; a written corrective action plan was required before the license is renewed.
Deficiencies (3)
R 325.1922 Admission and retention of residents: Residents A and B’s service plans were not signed by the resident or authorized representative.
R 325.1931 Employees; general provisions: A shift supervisor was not identified on various days and shifts from May 20, 2026, through May 23, 2026, including the 10:00 PM to 6:00 AM shift.
R 325.1970 Water supply systems: The water temperature in room 12 was 129.6 degrees Fahrenheit and in room 8 was 103.8 degrees Fahrenheit, not within the required range of 105 to 120 degrees.
Report Facts
Corrective action plan due: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Bendele | Administrator | Named in the finding about unsigned service plans. |
Inspection Report — Feb 3, 2026
Complaint Investigation
Date: Feb 3, 2026
Visit Reason
Investigation of a complaint received on 2026-01-29 about medication administration and staff practices.
Complaint Details
Unsafe staff practices including neglect and improper diapering of Resident A: not established. Resident B not getting medication due to aggressive dog, narcotic books not signed, and unlocked medicine cabinets: established. Additional findings: none.
Findings
One rule violation was established related to medication administration due to an aggressive dog preventing medication delivery. Another allegation of unsafe staff practices was not established.
Deficiencies (1)
R 325.1932 Resident medications: the facility did not comply with the rule as Resident B did not receive medication due to an aggressive dog preventing access.
Report Facts
Corrective action plan due: 15
Inspection Report — Jan 11, 2024
Complaint Investigation
Date: Jan 11, 2024
Visit Reason
Investigation of a complaint received on 2024-01-10 about inadequate interventions to prevent falls.
Complaint Details
The Resident of Concern was not provided with appropriate interventions to prevent falls: established. Additional findings: service plan not updated to reflect care needs: established.
Findings
Two rule violations were established related to failure to provide adequate fall prevention interventions and failure to update the resident's service plan to reflect significant changes in care needs.
Deficiencies (2)
R 325.1921 Governing bodies, administrators, and supervisors: the facility failed to maintain an organized program to provide protection and supervision to prevent falls for the Resident of Concern (ROC), who had 11 documented falls with no effective interventions to decrease falls.
R 325.1922 Admission and retention of residents: the facility did not update the ROC's service plan to reflect significant changes in care needs related to frequent falls, failing to cover all necessary aspects of care.
Report Facts
Corrective action plan due: 15
Inspection Report — Nov 7, 2023
Renewal
Date: Nov 7, 2023
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The home was found in non-compliance with 9 rules; a written corrective action plan was required before the license is renewed.
Deficiencies (8)
R 325.1913 Licenses and permits; general provisions: the facility failed to provide written notice to the department of the appointment of a new administrator on 8/21/2023.
R 325.1922 Admission and retention of residents: Resident C and Resident D's service plans were incomplete and lacked specific care and maintenance details.
R 325.1931 Employees; general provisions: the designated shift supervisor was not identified on the October 2023 staff schedule and was not always present on second shift. Repeat violation.
R 325.1932 Resident medications: medication administration records were incomplete or inaccurate for Residents A, B, and C, and PRN medication instructions were insufficient or duplicated.
R 325.1943 Resident registers: the resident register was incomplete, missing face sheets and licensed health care professional information for Residents E and F.
R 325.1964 Interiors: memory care apartments 2 and 7 lacked adequate and discernable air flow. Repeat violation.
R 325.1970 Water supply systems: hot water temperature in memory care apartments 2 and 7 was 103.8 degrees Fahrenheit, below the required range.
R 325.1976 Kitchen and dietary: sanitization logs for chemical sanitization and three-compartment sink were incomplete for multiple dates in October 2023.
Report Facts
Corrective action plan due: 15
Inspection Report — Sep 15, 2023
Complaint Investigation
Date: Sep 15, 2023
Visit Reason
Investigation of a complaint received on 2022-08-24 about resident-to-resident altercations and staff ability to manage aggressive residents.
Complaint Details
The facility did not provide interventions to prevent resident-to-resident altercations between the Resident of Concern (ROC) and Resident B: established. The facility’s director spoke about the ROC’s problematic toileting behaviors in front of individuals not authorized to know that information: not established. Care staff members did not seem to be able to deal with aggressive residents living in the memory care unit: established.
Findings
Two rule violations were established related to lack of interventions to prevent resident altercations and inadequate staff training on dementia-related behaviors. One allegation regarding privacy violation was not established.
Deficiencies (2)
R 325.1921 Governing bodies, administrators, and supervisors: the facility did not have a plan to provide appropriate interventions for residents involved in altercations, and no changes were made to the ROC’s service plan to address increasing agitation and aggression.
R 325.1931 Employees; general provisions: only one of four caregivers providing care to the ROC had completed all required dementia training modules to manage dementia-related behaviors.
Report Facts
Corrective action plan due: 15
Inspection Report — Aug 31, 2023
Complaint Investigation
Date: Aug 31, 2023
Visit Reason
Investigation of a complaint received on 2023-08-30 about Resident A not receiving breathing treatments as ordered.
Complaint Details
Resident A did not get her breathing treatments: established. Additional findings: not established.
Findings
One rule violation was established regarding medication administration delays for Resident A.
Deficiencies (1)
R 325.1932 Resident medications: Resident A had a physician order dated 8/10/2023 for breathing treatments but did not receive the medication until 8/12/2023, resulting in non-compliance with the rule.
Report Facts
Corrective action plan due: 15
Inspection Report — Aug 24, 2015
Original Licensing
Date: Aug 24, 2015
Visit Reason
Original license application for a home for the aged.
Findings
The facility is in substantial compliance with home for the aged public health code and administrative rules.
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