Inspection Reports for
Shelby Comfort Care Assisted Living and Memory Care

R 325.1976 Kitchen and dietary: the kitchen was not maintained in a sanitary and safe manner; refrigerator and dishwasher temperature logs were not maintained; multi-use utensils were soiled; multiple perishable and nonperishable food items were opened, not dated, and improperly stored.

MCL 333.20201 Policy describing rights and responsibilities of patients or residents: Resident A was observed restrained to a wheelchair with a gait belt not within policy; care needs were not consistently charted, making it unclear if ADL care needs were met.

R 325.1954 Meal and food records: the facility did not maintain meal census logs as required.

R 325.1932 Resident medications: the facility did not comply with the rule as four residents had days when medications were not administered as ordered.

R 325.1931 Employees; general provisions: the home failed to provide care consistent with Resident B’s service plan, including improper transfer methods and unclear wound care responsibilities.

R 325.1932 Resident medications: the facility failed to comply with medication administration policies, resulting in unaccounted controlled substances and incomplete narcotic count documentation.

R 325.1931 Employees; general provisions: Resident A experienced 7 documented falls in 30 days and the facility did not consistently implement interventions to prevent future falls and ensure resident safety.

MCL 333.20201 Policy describing rights and responsibilities of patients or residents; adoption; posting and distribution; 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: The facility did not provide bathing assistance as indicated on service plans and failed to follow their fall prevention policy for formulating fall interventions and entering them on residents’ service plans.

R 325.1932 Resident medications: Medications were administered outside the timeframe of the orders of the licensed health professional and contrary to the facility's policy, with documented late medication administration for multiple residents.

MCL 333.20201 Policy describing rights and responsibilities of patients or residents: the facility did not protect Resident B from sexual abuse perpetrated upon her by Resident A and has not put intervention into place to protect Resident B, other female residents or female caregivers from Resident A’s sexual aggressiveness.

R 325.1921 Governing bodies, administrators, and supervisors: the facility failed to maintain an organized program to provide protection, supervision, and assistance to residents, resulting in Resident B being sexually assaulted by Resident A.

R 325.1932 Resident medications: medications were not administered as ordered by the licensed health care professional and in accordance with the facility's policy.

R 325.1932 Resident medications: the facility was not informing the medication prescriber when medications were not being administered as ordered or refused by residents.

R 325.1979 General maintenance and storage: direct observation at the time of the onsite visit revealed that the facility was not kept clean with visible debris on floors and full waste cans.

MCL 333.20201 Policy describing rights and responsibilities of patients or residents: the facility barred a family member from visiting without offering an opportunity to visit under controlled circumstances.

R 325.1922 Admission and retention of residents: the service plan had not been updated to reflect the Resident of Concern’s true care needs and it is questionable that he received the required prompting, cueing and coaching.