Inspection Report
Renewal
Census: 18
Capacity: 65
Deficiencies: 5
Apr 8, 2025
Visit Reason
The inspection was conducted as a renewal licensing study for Brookdale Adrian to assess compliance with state regulations and licensing requirements.
Findings
The facility was found to be non-compliant with several state rules including inadequate documentation and safety measures for bedside assist devices, failure to identify shift supervisors on schedules, incomplete meal and food records, improper cleaning and sanitizing of kitchen utensils, and undated food items in the refrigerator. Repeat violations were noted for incomplete dish machine temperature logs.
Deficiencies (5)
| Description |
|---|
| Bedside assist devices lacked covers and necessary documentation such as risk evaluation, physician orders, and negotiated risk agreements were missing. |
| Shift supervisor was not identified on the schedule from 3/30/2025 to 4/12/2025. |
| Meal census records were maintained but the kind and amount of food used were not tracked. |
| Incomplete temperature logs for the high temperature dish machine for February and March 2025, with multiple meal periods left blank. |
| Several food items in the dining room refrigerator were not dated, including applesauce, sandwiches, and mandarin oranges. |
Report Facts
Capacity: 65
Residents observed/interviewed: 18
Staff observed/interviewed: 10
Dates with missing dish machine temperature logs: 9
Dates with missing dish machine temperature logs: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chris Lender | Administrator | Named in findings related to bedside assist device and shift supervisor schedule |
Inspection Report
Renewal
Deficiencies: 0
Mar 11, 2024
Visit Reason
The document serves as a renewal notification for the Home for the Aged license following an administrative review of licensing activity over the past year.
Findings
The administrative review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.
Inspection Report
Renewal
Census: 18
Capacity: 65
Deficiencies: 5
Mar 16, 2023
Visit Reason
The inspection was conducted as a Renewal Licensing Study Report to assess compliance with licensing requirements and determine if the facility's license should be renewed.
Findings
The facility was found to be non-compliant with several rules including inadequate ventilation in bathing/toileting areas, failure to post weekly therapeutic diet menus, incomplete dish machine temperature logs, lack of annual tuberculosis risk assessment, and incomplete narcotic count documentation.
Deficiencies (5)
| Description |
|---|
| Inadequate and discernable air flow in resident bathing/toileting facilities (room 30). |
| Failure to prepare and post weekly therapeutic or special diet menus. |
| Incomplete dish machine temperature logs for January, February, and March 2023, including future dates being logged. |
| Facility had not conducted and maintained an annual tuberculosis risk assessment. |
| Staff did not always sign narcotic count sheets as required on multiple dates and shifts. |
Report Facts
Number of staff interviewed and/or observed: 12
Number of residents interviewed and/or observed: 18
Facility capacity: 65
Dates with incomplete dish machine temperature logs: 7
Number of excluded employees followed up: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christopher Lender | Administrator/Licensee Designee | Interviewed regarding tuberculosis risk assessment |
| Employee #1 | Interviewed regarding narcotic count procedures and documentation |
Inspection Report
Original Licensing
Capacity: 65
Deficiencies: 0
Jun 15, 2015
Visit Reason
The visit was conducted as an addendum to the original licensing study report to process a facility name change request from Grand Court Adrian to Brookdale Adrian.
Findings
The facility name was officially changed on 2015-06-15 as part of a rebranding project with no changes in ownership, operations, or location. The licensing staff recommended approval of the name change.
Report Facts
Facility capacity: 65
Inspection Report
Original Licensing
Capacity: 65
Deficiencies: 0
Jul 16, 2009
Visit Reason
The visit was conducted as an addendum to the original licensing study report to amend the licensee name for Grand Court Adrian, per a request by the authorized representative.
Findings
Verification of the submitted documentation was completed via the Michigan Department of Energy, Labor and Economic Growth, Corporation Division’s Business Services website. It was recommended that the licensee name be amended from BLC Adrian-GC, LLC to Grand Court Adrian.
Inspection Report
Original Licensing
Capacity: 65
Deficiencies: 14
Apr 20, 2004
Visit Reason
The inspection was conducted as part of the original licensing study for the facility Grand Court Adrian to evaluate compliance with applicable regulations and determine eligibility for licensing.
Findings
Multiple violations were identified including failure to document PRN medication administration, lack of criminal history checks for employees, failure to lock medication carts, absence of required physician certificates and chest x-rays for residents, inadequate incident reporting, hot water temperature exceeding limits, food protection failures, missing thermometers in refrigerators, and incomplete employee training documentation.
Deficiencies (14)
| Description |
|---|
| Medications administered as needed (PRN) were not documented as required in two of six resident records reviewed. |
| Seven of seven personnel files failed to include a criminal history check as required by law. |
| Staff failed to lock the medication cart when leaving the area during medication administration. |
| Facility failed to obtain a waiver for a resident under the age of 60 years. |
| Smoking prohibition signs were not posted at each entrance and designated smoking area signs were missing. |
| Two of six resident records lacked physician certificates indicating freedom from communicable disease. |
| Two of six resident records lacked chest x-rays performed within 3 months prior to admission. |
| One of seven employee files lacked a preemployment physical examination. |
| Twenty of thirty-three incident reports did not notify the physician as required. |
| Eight of thirty-three incident reports did not include corrective measures to avoid repetition of accidents or incidents. |
| Hot water temperature exceeded 110 degrees Fahrenheit in nine of thirteen plumbing fixtures tested. |
| Food being served was not protected against contamination from dust and other sources. |
| Freezer sections of refrigerators did not have reliable thermometers in place. |
| In six of seven employee personnel files, it could not be determined if employees received training to perform assigned tasks as specified in disaster plans. |
Report Facts
Resident records reviewed: 6
Personnel files reviewed: 7
Incident reports reviewed: 33
Hot water fixtures tested: 13
Hot water fixtures exceeding temperature limit: 9
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