Inspection Reports for Brownstown Forest View Assisted Living

Complaint received on 07/23/2025 alleged staff retaliation for reporting discrepancies and residents being soiled/neglected due to short staffing. Violation was established based on investigation findings.

The investigation found that resident care needs were not being met, with staffing shortages especially on afternoon and midnight shifts. Medication carts were soiled and narcotic book documentation was incomplete. Several employee files lacked proper education and competency documentation. Missing charting was noted for multiple residents.

The complaint alleged that Resident A was found on 3/23/2025 in a recliner with only a brief and cardigan, soaked with urine, and without proper clothing. The complaint was substantiated with a violation established due to inadequate care and supervision.

The investigation found that Resident A was found sitting in a recliner wearing only a brief and a cardigan, with staff failing to provide adequate supervision on the second floor between approximately 7am and 9:45am. Staff 3 arrived late and did not immediately attend to the assigned floor, resulting in Resident A being unsupervised and inadequately cared for during that time.

Complaint received on 2024-12-10 alleged Resident A was left alone in her room and the facility was understaffed, Resident A and other residents were not receiving medications as ordered including nighttime medications, and the facility was dirty with an unsecured front door. The allegation of understaffing and Resident A being left alone was not substantiated. The medication and facility cleanliness/security allegations were substantiated.

The allegation that Resident A was left alone and the facility was understaffed was not substantiated. However, violations were established for residents not receiving medications as ordered, with multiple missed medication administrations documented, and for the facility being dirty with an unsecured front door and maintenance issues such as dust buildup and peeling paint.

The facility was found to be non-compliant with multiple rules including tuberculosis screening for residents and employees, interior maintenance issues such as peeling paint, dust buildup, water damage, ventilation failures, overflowing garbage, and improper storage of hazardous materials. A corrective action plan is required to address these violations.

Complaint received on 03/25/2024 alleged verbal abuse, neglect, lack of showers, dirty rooms, employees without background checks, and residents yelling for help. Violation of resident neglect was established.

The investigation established a violation of resident neglect due to improper resident transfer techniques and the facility's inability to provide shower sheets for several residents. Background checks were confirmed for employees, and the facility was observed to be clean with residents appropriately groomed and engaged.

Complaint allegations included inappropriate resident placement, Resident A eloping, and staff not trained leading to missing medications. The investigation substantiated the training and medication issues but did not substantiate the other allegations.

The investigation found no violation regarding inappropriate resident placement or Resident A eloping. However, a violation was substantiated due to staff lacking training records and residents missing medications. Interviews and record reviews confirmed that some staff lacked proper training documentation, though medication administration was observed to be properly conducted.

Complaint alleged Resident A's personal care needs were not met, including bathing and shaving, and that Resident A's room was dirty. The complaint was substantiated for personal care needs but not for room cleanliness.

The investigation established violations related to Resident A not receiving adequate personal care, including insufficient bathing frequency and a lack of detail in the service plan. The complaint about the cleanliness of Resident A's room was not substantiated. Additional findings included Resident A's combative and abusive behavior towards staff and other residents, posing a risk of harm.

Complaint received from adult protective services (APS) on 09/07/2023 alleging staff passed medications without training, Resident A did not receive showers, staff did not follow physicians' orders, and narcotics were stored improperly. The violation for untrained medication administration was established; other allegations were not substantiated.

The investigation established a violation that staff passed medications without proper training, specifically that Associate 1 was scheduled as a medication technician before completing training. The allegations that Resident A did not receive showers, staff did not follow physicians' orders, and narcotics were stored improperly were not substantiated.