7 Reports
Inspection Report — Oct 14, 2025
Complaint Investigation
Date: Oct 14, 2025
Visit Reason
Investigation of a complaint received on 2025-10-13 about inadequate care, hygiene, medication administration, and facility conditions.
Complaint Details
Residents not being changed or showered regularly: established. Resident found unchanged with pressure wounds worsening: established. Resident left facility and owner refused to call 911: established. Staff aware of sexual abuse: not established. Facility unsanitary water: not established. Bathrooms/showers poor condition: established. Bugs throughout facility: not established. Staff stealing medications: not established. Residents not receiving medications: established. Facility not serving nutritious meals or adequate portions: established.
Findings
Six rule violations were established related to resident care, hygiene, linens, safety and maintenance of premises, medication administration, and nutrition including diabetic diet and menu posting.
Deficiencies (6)
R 400.681 Resident rights; licensee responsibiliites: Resident J was not provided with personal care as required in assessment plan and Resident F was not provided adequate supervision and protection, resulting in multiple elopements. No sexual abuse was established despite Resident F's inappropriate behavior.
R 400.677 Resident hygiene, clothing: Residents were not consistently assisted with hygiene; some residents were found with multiple briefs on, strong odors, and infrequent bathing due to refusal or inadequate assistance.
R 400.669 Linens: Resident E, Resident L, and Resident N reported that bed linens were not washed regularly.
R 400.647 Safety and maintenance of premises: Bathrooms had maintenance issues including missing toilet tank lid, chipped tiles, unsecured vent fan, rusted toilet chair, chipped flooring, and missing shower curtain, some of which were repaired after inspection.
R 400.675 Resident medications: Resident E did not receive prescribed medication doses on time due to staff issues; medications were found unsecured in resident's room without physician authorization initially, later corrected.
R 400.663 Nutrition; adoption by reference: Residents reported small food portions and poor quality meals; diabetic diet was not properly provided; menus were not posted timely; facility failed to provide nutritious meals and appropriate diabetic options.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Penny Lovett | Home Manager | Named in hygiene, showering, and resident care findings. |
| Jenna Pierson | Assistant Manager | Named in hygiene and resident care findings. |
| William Gross | Licensee Designee | Named in multiple findings including medication and facility conditions. |
| Domonjie Smith | Cook | Named in food service and kitchen condition findings. |
Inspection Report — Jul 16, 2025
Complaint Investigation
Date: Jul 16, 2025
Visit Reason
Investigation of a complaint received on 2025-07-16 about failure to seek medical care and inadequate treatment of a resident's injuries.
Complaint Details
Failure to notify legal guardian of accident: established. Failure to protect resident: not established.
Findings
One rule violation was established regarding failure to notify the legal guardian immediately of an accident involving severe burns to Resident A. Another alleged violation about protection and safety was not established.
Deficiencies (1)
R 400.2402 Change in health and accidents: the facility failed to notify Resident A's legal guardian immediately of the firecracker accident on 07/03/2025 when it occurred.
Report Facts
Corrective action plan due: 15
Inspection Report — Apr 18, 2025
Complaint Investigation
Date: Apr 18, 2025
Visit Reason
Investigation of a complaint received on 2025-04-17 about staffing, groceries, and laundry detergent.
Complaint Details
There is a staff at the home that is not working legally and does not speak English: not established. The home does not have any groceries or laundry detergent: not established. Additional findings: water supply deficiencies — established.
Findings
Two allegations were investigated and found not established. One additional finding regarding water supply deficiencies was established, requiring a corrective action plan.
Deficiencies (2)
R 400.2431 Home environment: the facility's water system had deficiencies with the source, distribution system, and operator compliance as identified in the EGLE Deficiency Violation Notice dated 05/08/2025.
R 400.2448 Water and sanitation: the private water system did not meet public health rules, with unresolved deficiencies as of the extended deadline and a waiver request submitted.
Report Facts
Corrective action plan due: 15
Inspection Report — Jun 14, 2024
Complaint Investigation
Date: Jun 14, 2024
Visit Reason
Investigation of a complaint received on 2024-06-12 about multiple allegations including staffing, medication errors, facility conditions, and resident care.
Complaint Details
Spanish speaking employee passing medications only in English: not established. Staff may not be legal or have background checks: established. Two males working same shift without female: not established. Building too hot and humid with slippery floors: established. Resident O double dose medication: not established. Resident I not receiving insulin: established. Multiple medication errors due to untrained staff: established. Guardian/provider not notified of hospitalizations and death: established. Staff lacked batteries for blood pressure cuff: not established. Staff drinking, sleeping, inappropriate behavior, boyfriend visiting: established. Resident J locks himself in bathroom without keys: not established. Only one bathroom working, residents not receiving showers: not established. Unsanitary food preparation: not established. Additional findings: missing resident funds and financial exploitation: established. Poor housekeeping and bed conditions: established.
Findings
Multiple violations were established including lack of workforce background checks, inadequate home environment temperature, failure to notify guardians and providers of hospitalizations and deaths, medication administration errors, financial exploitation of residents, inappropriate staff behavior, insufficient bathroom facilities, and poor housekeeping standards. Some allegations were not substantiated or were corrected.
Deficiencies (13)
MCL 400.713 License required; application; forms; investigation; on-site evaluation; issuance or renewal of license; disclosures; maximum number of persons; stating type of specialized program; issuance of license to specific person at specific location; transferability of license; sale of facility; notice; items of noncompliance; refusal by department to issue or renew license; conditions; unlicensed facility; violation as misdemeanor; penalty; receipt of completed application; issuance of license within certain time period; inspections; report; criminal history and records check; storage of fingerprints in automated fingerprint identification system database; convictions; "completed application" defined: workforce background checks were not provided for several staff listed on the schedule.
R 400.2431 Home environment: dining, bath, sitting, living, and recreation rooms were maintained at 78.6 degrees Fahrenheit during nonsleeping hours, exceeding the required 68-72 degrees.
R 400.2402 Change in health and accidents: guardian and responsible parties were not notified of Resident P’s hospitalization from 07/08/2024 to 07/10/2024 as required.
R 400.2405 Deaths of residents: Resident S’s death on 07/05/2024 was not reported within 72 hours and guardian notification was not documented.
R 400.2415 Health care of residents: multiple medication logs for residents had missing staff initials, missing instructions, and medication administration errors including Resident I not receiving insulin as prescribed.
R 400.2412 Care of residents: staff Jozlyn and Stephanie engaged in inappropriate behaviors including sleeping on the job, inappropriate clothing, and allowing a boyfriend to visit overnight; both staff were terminated.
R 400.2412 Care of residents: Resident J locks himself in bathroom but staff have access to keys; no violation established for lack of keys.
R 400.2413 Residents; personal care: insufficient working bathrooms for the facility capacity of 31 residents; only one bathroom was usable with shower, others were out of order or unusable.
R 400.2471 Quality of meals: food preparation was sanitary, kitchen clean, no expired food or canned goods observed; no violation established.
R 400.2421 Residents' funds; access; safekeeping: resident funds were missing, residents did not have access to at least $5.00 of their personal funds, and staff were unable to access locked box containing funds.
R 400.2457 Resident funds and valuables: facility was unable to provide any resident funds records and could not open box where funds were stored.
R 400.2412 Care of residents: residents were not protected from financial exploitation; missing resident funds were alleged to be taken by former nurse practitioner but no evidence provided.
R 400.2431 Home environment: strong smell of urine throughout building, bedrooms unkept, beds in disarray with one soaked in urine, and two beds needing repair with duct tape.
Report Facts
Corrective action plan due: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| William Gross | Licensee Designee | Named as licensee designee and participant in meetings and communications |
| Kimberlee Mitchell | Home Manager | Named as home manager involved in investigations and meetings |
| Jocey William | Staff | Named as staff interviewed during investigations |
| Serena Wisner | Staff | Named as staff interviewed during investigations |
| Ana Amador | Staff | Named as staff involved in resident funds and investigations |
| Shawneesha Cooper | Staff | Named as staff involved in investigations and meetings |
| Jim Sealey | Cook | Named as cook interviewed regarding food preparation |
| Demarus Mullins | Home Manager | Named as new home manager interviewed during later investigation |
| Kalista Martin | Staff | Named as staff interviewed during later investigation |
Inspection Report — Apr 19, 2024
Complaint Investigation
Date: Apr 19, 2024
Visit Reason
Investigation of a complaint received on 2024-04-17 about medication administration, phone access, and food and supplies at the facility.
Complaint Details
Medication administration issues: established. Resident phone access restrictions: established. Lack of nutritious food and unnoted menu substitutions: established. Care and supplies: not established.
Findings
Three rule violations were established regarding medication administration, resident phone access, and meal quality and planning. One allegation about care and supplies was not established.
Deficiencies (3)
R 400.2415 Health care of residents: medication logs showed missing staff initials and missed medication administration and checks for Resident A and Resident C, establishing a violation.
R 400.2418 Resident activities: the facility had inconsistent phone usage policies requiring calling cards for outgoing calls, which residents were not consistently provided, establishing a violation.
R 400.2471 Quality of meals and R 400.2474 Meal Planning: the facility lacked consistent availability of nutritious foods including fresh fruits and vegetables, and menu substitutions were not noted, establishing violations.
Report Facts
Corrective action plan due: 15
Inspection Report — Jul 21, 2023
Complaint Investigation
Date: Jul 21, 2023
Visit Reason
Investigation of a complaint received on 07/21/2023 about medication safety, staffing, and home environment.
Complaint Details
Staffing adequacy: not established. Medication safeguarding: established. Additional findings: broken shower head and damaged bathroom fixtures — established.
Findings
Three rule violations were established related to medication safeguarding and home environment; one allegation regarding staffing was not established.
Deficiencies (3)
R 400.2415 Health care of residents: medications were observed in cups on the kitchen counter with an open door, accessible to residents and visitors; medication room door was propped open and medication packs were unsecured in the manager’s office.
R 400.2431 Home environment: a broken shower head was observed in Bathroom #2 and the door to Bathroom #3 would not shut all the way.
R 400.2431 Home environment: floors, walls and ceilings were damaged with wood trim broken and cracked tile at the bottom of bathroom walls.
Report Facts
Corrective action plan due: 15
Inspection Report — May 19, 2014
Date: May 19, 2014
Visit Reason
Addendum purpose: To properly list residents’ bedroom numbers and square footage.
Findings
Addendum to original licensing study report is recommended, with no change to the license.
Report Facts
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