Inspection Report Summary
The most recent inspection on February 28, 2025, identified deficiencies related to short staffing and unmet care needs for a resident. Earlier inspections showed a pattern of issues including staffing shortages, incomplete documentation, and safety concerns such as fall prevention and staff training. Complaint investigations substantiated several allegations, particularly regarding resident care and supervision, though no fines or enforcement actions were listed in the available reports. Prior reports noted administrative documentation deficiencies and gaps in quality review programs. The inspection history indicates ongoing challenges with staffing and resident care, with no clear improvement trend evident.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
64% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 46
Capacity: 72
Deficiencies: 2
Date: Feb 28, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility was short-staffed and that Resident A experienced long wait times for staff assistance and unmet care needs.
Complaint Details
The complaint alleged that the facility was extremely short-staffed, causing Resident A to wait hours for assistance, and that Resident A's care needs were not being met, including severe neglect concerns. The allegations were substantiated based on interviews, record reviews, and observations.
Findings
The investigation substantiated that the facility was short-staffed and Resident A experienced long call light wait times averaging 19 minutes, with some exceeding 45 minutes. Resident A's care needs were not being met, including issues with hygiene, mobility, and lack of exposure to common areas. Documentation of refusals of care and care planning was minimal.
Deficiencies (2)
The facility is short-staffed, resulting in long wait times for Resident A's assistance.
Resident A's care needs are not being met, including severe skin breakdown, improper wheelchair fitting, and lack of social interaction.
Report Facts
Average daily census: 46
Total licensed capacity: 72
Average call light wait time: 19
Call light wait times greater than 45 minutes: Several instances during week 2/1/2025 through 2/20/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Quintina Young | Administrator | Interviewed regarding staffing goals and Resident A's care |
| Jennifer Heim | Health Care Surveyor | Conducted the investigation and authored the report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report |
Inspection Report
Renewal
Census: 35
Capacity: 72
Deficiencies: 2
Date: Jun 26, 2024
Visit Reason
The inspection was conducted as a renewal licensing study to assess compliance with regulatory requirements for the facility's license renewal.
Findings
The facility was found to be in non-compliance with rules regarding timely submission of administrator appointment documentation and the implementation of a quality review program consistent with statutory requirements.
Deficiencies (2)
Failure to submit required appointment documentation for new administrator since 5/03/2024.
Facility unable to provide evidence of a quality review program consistent with section 20175(8) of the act, MCL 333.20175, and the professional review function.
Report Facts
Number of staff interviewed and/or observed: 12
Number of residents interviewed and/or observed: 35
Facility capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tina Young | Administrator | Named as the new administrator since 5/03/2024 related to deficiency in appointment documentation |
Inspection Report
Complaint Investigation
Census: 10
Capacity: 72
Deficiencies: 2
Date: May 21, 2024
Visit Reason
The inspection was conducted in response to a complaint received on March 25, 2024, alleging lack of supervision and care of Resident A, staff training deficiencies, and food program concerns at Addington Place of Clarkston.
Complaint Details
Complaint received on 03/25/2024 regarding Resident A falling multiple times, lack of supervision, lack of staff training, lack of notification to hospice agency, emergency call cord not working, ADL assistance not performed daily, non-staff members assisting with meal pass, and poor food service management. Violation was substantiated.
Findings
The investigation substantiated the allegations of lack of supervision and care for Resident A, incomplete incident reports, and failure to implement effective fall prevention measures. Staff training was confirmed, but staffing shortages and incomplete safety measures contributed to safety risks. Food service was managed by staff only, with no evidence of non-staff involvement.
Deficiencies (2)
Failure to maintain safety and limit fall occurrences for Resident A.
Incomplete incident reports with missing pertinent data.
Report Facts
Facility capacity: 72
Census during investigation: 10
Staffing: 1
Staffing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tina Young | Administrator | Interviewed onsite and provided facility documents |
| Jennifer Heim | Licensing Staff | Author of the Special Investigation Report |
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 1
Date: Mar 6, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging staff were not properly trained and residents were neglected.
Complaint Details
Complaint alleged staff were not trained and residents were neglected, including lack of supervision and denial of basic needs. The staff training allegation was substantiated; the neglect allegation was not substantiated.
Findings
The investigation substantiated the allegation that staff were not properly trained due to lack of organized training documentation and competency verification. The allegation of resident neglect was not substantiated as residents' needs were met consistent with their service plans, and observations showed adequate staffing and care.
Deficiencies (1)
Staff were not properly trained, with incomplete training documentation and lack of competency verification for some employees.
Report Facts
Capacity: 72
Complaint Receipt Date: Feb 1, 2023
Investigation Initiation Date: Feb 2, 2023
Inspection Date: Mar 6, 2023
Report Due Date: Apr 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denise Lugar | Interim Administrator | Interviewed regarding staff training and facility staffing |
| Stephen Levy | Authorized Representative | Participated in exit conference |
| Jessica Rogers | Licensing Staff | Conducted inspection and authored report |
Inspection Report
Original Licensing
Capacity: 72
Deficiencies: 0
Date: Mar 1, 2022
Visit Reason
The document is an addendum to the Original Licensing Study Report reflecting a change in management company for the home for the aged facility effective March 1, 2022.
Findings
The management agreement indicates that the new management company, SLH HTI East Manager, LLC, will make reasonable efforts to obtain and maintain all required licenses and permits and comply with requirements related to the facility's home for the aged license. The license status is recommended to remain unchanged.
Report Facts
Facility capacity: 72
Management change effective date: Mar 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Clum | Licensing Staff | Author of the addendum and recommendation |
| Tyler May | Administrator | Facility administrator confirming management agreement |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the addendum |
Inspection Report
Original Licensing
Capacity: 72
Deficiencies: 0
Date: Nov 30, 2020
Visit Reason
The document serves as an addendum to the Original Licensing Study Report to document a change in management company and a proposed facility name change effective December 1, 2020.
Findings
The management company for the facility will change from Homestead Management Group, LLC to Cedarhurst of Clarkston Management, LLC, and the facility name will change from Autumn Ridge of Clarkston HFA to Addington Place of Clarkston effective December 1, 2020. The license status remains unchanged.
Report Facts
Facility capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jordan Houston | Authorized Representative/Administrator | Named as the authorized representative and administrator of the facility |
| Elizabeth Gregory-Weil | Licensing Staff | Author of the report and recommendation |
| Russell Misiak | Area Manager | Signed the recommendation for the report |
| Susan Rice | Vice President of Clinical Operations | Provided notification and documentation regarding management company change |
Inspection Report
Original Licensing
Capacity: 72
Deficiencies: 0
Date: Jan 14, 2015
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for the facility Autumn Ridge of Clarkston.
Findings
The study determined substantial compliance with applicable licensing statutes and administrative rules. The facility was found to be clean, well maintained, and equipped with appropriate safety features and resident accommodations.
Report Facts
Licensed capacity: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deanna McMahon | Administrator | Named as the facility's administrator and authorized representative. |
| Lilly Anne | Licensing Staff | Conducted the licensing study and signed the report. |
| Betsy Montgomery | Area Manager | Approved the licensing study report. |
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