Inspection Reports for
The Reflections
14316 S. Helmer Rd., Battle Creek, MI, 49015
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Inspection Report — Jun 7, 2024
Renewal State
Date: Jun 7, 2024
Visit Reason
The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing requirements and to determine if the facility meets standards for license renewal.
Findings
The facility was found to be in non-compliance with several rules including lack of detailed medication administration instructions in a resident's service plan, failure to complete the annual tuberculosis risk assessment, incomplete employee competency checklists, undated items in the walk-in refrigerator, and unsecured hazardous cleaning products in the dining room.
Deficiencies (5)
Resident A's service plan lacked detailed information on medication administration criteria for Lorazepam.
Facility did not complete the tuberculosis annual risk assessment.
Resident Care Associate Checklist and Medication Technician Performance Checklist were not completed for certain staff.
Walk-in refrigerator contained items that were not dated.
Cleaning products were not stored in a secure area, posing a risk to residents.
Report Facts
Number of residents interviewed and/or observed: 15
Number of staff interviewed and/or observed: 5
Number of excluded employees followed up: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonathon Zima | Administrator | Named as facility administrator |
| Todd Dockerty | Authorized Representative | Named as authorized representative |
Inspection Report — May 10, 2023
Renewal State
Date: May 10, 2023
Visit Reason
An administrative review of licensing activity for the past year was conducted to assess compliance with public health code and administrative rules regulating home for the aged facilities.
Findings
The review revealed substantial compliance with applicable regulations, resulting in the renewal of the Home for the Aged license for a 12-month period effective 06/09/2023.
Report Facts
License duration: 12
License effective date: Jun 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Author of the renewal letter |
Inspection Report — Dec 27, 2022
Complaint Investigation State
Date: Dec 27, 2022
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility improperly discharged Resident D without providing a less than 30-day discharge notice and failed to administer prescribed as needed Risperdal medication when Resident D exhibited behaviors.
Complaint Details
The complaint alleged improper discharge of Resident D without a less than 30-day discharge notice and failure to administer prescribed medication. The complaint was received from Adult Protective Services on 2022-12-09 and was not assigned for APS investigation. The violations were substantiated.
Findings
The investigation found that the facility did not provide Resident D or his authorized representative with a written less than 24-hour discharge notice and did not inform them of the right to file a complaint. Additionally, staff failed to administer Resident D's prescribed as needed Risperdal medication for agitation, and the resident's service plan lacked instructions for managing his behaviors.
Deficiencies (3)
Facility improperly discharged Resident D without providing a written less than 24-hour discharge notice and did not inform the responsible person of the right to file a complaint.
Staff did not administer Resident D's prescribed as needed Risperdal medication when he exhibited agitation and aggressive behaviors.
Resident D's service plan did not outline behaviors, staff interventions, or use of prescribed as needed Risperdal medication.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Reed | Nursing Director | Named in relation to the improper discharge and medication administration findings |
| Jonathon Zima | Administrator | Provided statements consistent with findings and supplied Resident D's service plan and medication records |
| Todd Dockerty | Authorized Representative | Named as the licensee's authorized representative and recipient of report findings |
Inspection Report — Nov 24, 2020
Original Licensing State
Date: Nov 24, 2020
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for The Reflections facility.
Findings
The facility was found to be in substantial compliance with home for the aged public health code and administrative rules. The report recommends issuance of a temporary license with a maximum capacity of 45.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Author of the licensing study report and signatory. |
| Russell B. Misiak | Area Manager | Approved the licensing study report. |
| Todd Dockerty | Authorized Representative of the applicant. | |
| Jonathan Zima | Administrator | Administrator of the facility. |
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