Inspection Reports for Bickford of West Lansing

The inspection was conducted as a Renewal Licensing Study to assess compliance with licensing requirements and to identify any violations that require corrective action.

The facility was found to be in non-compliance with multiple rules including lack of detailed medication administration plans, missing admission agreements, failure to conduct required tuberculosis screenings for residents and employees, incomplete staff training, medication administration documentation errors, inadequate ventilation in certain rooms, improper food labeling and disposal, and unsafe storage of hazardous materials. Many violations were repeat findings from previous inspections.

The investigation was initiated due to complaints alleging that Resident A did not receive her prescribed medications, specifically Keppra and Vimpat.

The investigation found that Resident A missed multiple doses of prescribed medications due to failures in medication ordering, administration, and documentation by facility staff. The facility also failed to ensure medication competency for self-administration and did not have proper medication orders at admission.

Complaint investigation initiated after allegations that Resident A did not receive her medications. The complaint was substantiated with violations established related to medication administration and facility procedures.

The inspection was initiated due to a complaint received from Adult Protective Services alleging that Resident B left the facility unattended.

The investigation confirmed that Resident B left the facility unattended on 07/13/2024, contrary to the resident's service plan which stated Resident B was not to be left unattended outside the community. The facility failed to ensure Resident B's protection by not following the service plan.

Complaint received from Adult Protective Services alleging Resident B left the facility unattended. APS denied the allegations but the investigation established the violation.

The investigation was initiated due to a complaint alleging neglect of Resident A's basic care needs, including failure to change bed linens and provide showers, as well as concerns about understaffing and food quality.

The investigation found that the facility did not neglect Resident A's basic care needs or food quality but did establish violations for Resident A not receiving showers as scheduled, understaffing impacting resident care, and failure to update service plans for residents adequately.

Complaint received from Adult Protective Services alleging neglect of Resident A's basic care needs, including unclean bed linens and lack of showers. APS denied opening the investigation. The complaint also included allegations of understaffing and poor food quality.

The inspection was conducted in response to a complaint alleging violations including Resident B's privacy being violated, Resident A not receiving nightly checks, incorrect medications administered to Resident A, Resident A not receiving showers, and Resident A's sheets not being changed.

The investigation established violations for Resident B's privacy being violated, Resident A not receiving nightly checks, and incorrect documentation of medication administration after Resident A's discharge. The allegation of incorrect medications administered to Resident A was not substantiated, nor were allegations regarding Resident A not receiving showers or sheets not being changed.

The complaint alleged Resident B’s privacy was violated, Resident A did not receive nightly checks, Resident A received incorrect medications, Resident A did not receive showers, and Resident A’s sheets were not changed. Violations were substantiated for privacy violation, lack of nightly checks, and incorrect medication documentation. The medication error allegation was not substantiated, nor were the shower and sheet allegations.

The inspection was conducted in response to a complaint alleging money was stolen from Resident A, increased wait times for assistance, and failure to provide showers to Resident A.

The investigation found no violation regarding the stolen money allegation and the shower allegation, but established a violation for increased wait times for assistance, with an average call light response time of 21 minutes, exceeding the facility expectation of five minutes.

The complaint alleged money was stolen from Resident A, Resident A had increased wait times for assistance, and Resident A did not receive showers. The money stolen allegation was not substantiated. The increased wait times allegation was substantiated. The shower allegation was not substantiated.

The inspection was initiated due to a complaint alleging that Resident C was not provided timely medical attention for a urinary tract infection and did not receive required laboratory testing.

The investigation established a violation that Resident C was not provided timely medical attention and that prescribed medication was not administered as documented. The allegation that Resident C did not receive required INR laboratory testing was not established due to lack of evidence. Additional findings included failure to document medication administration for Resident C's prescribed antibiotic.

The complaint alleged Resident C experienced delays in receiving a urinalysis test and antibiotic treatment for a urinary tract infection. The complaint also alleged Resident C did not receive required INR laboratory testing while at the facility.

The investigation was initiated due to a complaint alleging that Resident A's bathroom was flooded resulting in mold.

The investigation confirmed the bathroom flooding occurred and was properly addressed with cleaning, drywall replacement, repainting, and mold assessment which found no mold. However, a detectable cat urine odor and scattered litter were observed in Resident A's room, indicating the room was not clean and in good repair. Additionally, Resident A's service plan inaccurately reflected independence in pet care, as staff assistance was provided.

The complaint alleged that Resident A's bathroom was flooded resulting in mold. The violation was established as the flooding occurred and the room was not maintained clean and in good repair due to cat urine odor and litter issues. The service plan was also found inaccurate regarding pet care independence.

The inspection was conducted in response to a complaint alleging that the boiler was not working and there was no hot water in the facility.

The investigation confirmed that the boiler did not maintain appropriate hot water temperatures, affecting resident showers, laundry, and kitchen sanitization. Multiple repairs were made, but the boiler requires replacement, especially with the upcoming winter season.

The complaint alleged that the boiler was not working and there was no hot water in the home. The allegation was substantiated based on interviews, on-site investigation, and review of maintenance records.

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.

The facility was found to be in substantial compliance overall but had multiple deficiencies including lack of detailed medication administration plans, invalid admission agreements, missing tuberculosis screenings and risk assessments, inadequate employee health screenings, ventilation and maintenance issues, unsafe storage of hazardous materials, lack of written disaster plans, and improper food handling and storage practices.

The inspection was conducted in response to a complaint alleging the facility failed to provide Resident A with medications after a hospital stay due to a pharmacy computer issue.

The investigation found that Resident A did not receive medications for several days due to a pharmacy system issue, but the family assisted with medication administration. The facility failed to complete the medication log for some medications, resulting in a violation being established.

Complaint alleged the facility failed to provide Resident A with medications due to a pharmacy computer issue causing medications to remain in discontinued status after hospital discharge. The complaint was not substantiated for failure to provide medications but substantiated for failure to complete medication logs.

The document serves as a renewal notification for the Home for the Aged license of Bickford of W Lansing, confirming substantial compliance with public health code and administrative rules over the past year.

An administrative review revealed substantial compliance with applicable regulations, resulting in the renewal of the facility's license for 12 months effective 12/09/22.

The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Bickford of W Lansing.

The study determined substantial compliance with licensing statutes and administrative rules, resulting in the recommendation to issue a temporary license with a maximum capacity of 72 residents.