Inspection Report
Renewal
Census: 30
Capacity: 66
Deficiencies: 3
Jan 18, 2024
Visit Reason
The inspection was conducted as a renewal licensing study for Candlestone Assisted Living to assess compliance with regulatory requirements and determine eligibility for license renewal.
Findings
The facility was found to be in non-compliance with several rules including failure to provide an annual tuberculosis (TB) risk assessment for residents and staff, and failure to provide evidence of a quality review program for incident reporting as required by state regulations.
Deficiencies (3)
| Description |
|---|
| Facility unable to provide an annual TB risk assessment which included residents. |
| Facility unable to provide an annual TB risk assessment which included staff. |
| 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: 9
Number of residents interviewed and/or observed: 30
Facility capacity: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sara Dickendesher | Authorized Representative | Named as authorized representative of the facility |
| Marcie Edwards | Administrator | Named as facility administrator |
Notice
Deficiencies: 0
Jan 30, 2023
Visit Reason
The document serves as a notification that the Home for the Aged license for Candlestone Assisted Living has been renewed for a 12-month period effective March 1, 2023.
Findings
The letter confirms the renewal of the facility's license and states that the license is valid only at the listed address and is not transferable.
Report Facts
License duration: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Clum | Licensing Staff | Author of the license renewal notification letter |
Inspection Report
Complaint Investigation
Capacity: 66
Deficiencies: 1
Dec 20, 2022
Visit Reason
The investigation was initiated due to a complaint alleging that the facility did not have a plan to manage Resident A's aggressive behavior causing injury to Resident B, and that the facility failed to investigate an injury sustained by Resident B after the altercation.
Findings
The investigation found no violation regarding the facility's plan to manage Resident A's aggression, but established a violation for failure to properly investigate and report an injury (bruise) sustained by Resident B following the altercation with Resident A.
Complaint Details
The complaint alleged that Resident A became aggressive and caused injury to Resident B during a community activity on 11/3/2022, and that the facility failed to investigate a bruise on Resident B's hand reported by Resident B's family member. The complaint was substantiated for failure to investigate the injury.
Deficiencies (1)
| Description |
|---|
| The facility did not investigate an injury sustained by Resident B that was discovered by Resident B’s family member after the physical altercation with Resident A. |
Report Facts
Capacity: 66
Complaint Receipt Date: Nov 7, 2022
Investigation Initiation Date: Nov 9, 2022
Inspection Date: Dec 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara P. Zabitz | Health Care Surveyor | Author of the investigation report |
| Marcie Edwards | Administrator | Facility administrator interviewed during onsite visit |
| Sara Dickendesher | Authorized Representative | Authorized representative who reviewed findings |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the investigation report |
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