Inspection Reports for Charlotte Stephenson A ProMedica Senior Living Community
MI, 49221
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Inspection Report
Renewal
Census: 25
Capacity: 59
Deficiencies: 3
Jan 13, 2025
Visit Reason
The inspection was conducted as a renewal licensing study to evaluate compliance with state regulations and determine if the facility's license should be renewed.
Findings
The facility was found to be non-compliant with several rules including failure to update resident service plans annually, missing staff training documentation, and incomplete medication administration records. Repeat violations were noted from a prior Licensing Study Report dated 12/6/2022.
Deficiencies (3)
| Description |
|---|
| Resident service plans were not updated annually or after significant changes; Resident A lacked a service plan. |
| Employee #1's file was missing required training documentation and medication training was undated. |
| Medication administration records for Resident B had blank entries on 11/17/2024 and 12/15/2024; insufficient instructions for prn medications for Residents B and C. |
Report Facts
Number of staff interviewed and/or observed: 12
Number of residents interviewed and/or observed: 25
Facility capacity: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in finding for missing training documentation and undated medication training |
Inspection Report
Renewal
Deficiencies: 0
Jul 23, 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 review revealed substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.
Report Facts
License effective date: Aug 1, 2024
Inspection Report
Renewal
Census: 25
Capacity: 59
Deficiencies: 4
Dec 6, 2022
Visit Reason
The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing rules and regulations for the facility.
Findings
The facility was found to be non-compliant with several rules including failure to update resident service plans annually, incomplete medication supervision instructions in service plans, failure to post therapeutic diet menus, and inadequate ventilation in certain rooms.
Deficiencies (4)
| Description |
|---|
| Resident service plan was not updated annually or after significant change in care needs. |
| Resident medication supervision was not always addressed in the service plan, lacking instructions for pain management. |
| Therapeutic or special diet menus were not posted as required. |
| Inadequate and discernable air flow in residents’ bathing/toileting facilities, beauty salon, and soiled laundry rooms. |
Report Facts
Number of staff interviewed and/or observed: 12
Number of residents interviewed and/or observed: 25
Facility capacity: 59
Date of on-site inspection: Dec 6, 2022
Date of exit conference: Dec 7, 2022
Date of Bureau of Fire Services Inspection: Nov 16, 2022
Inspection Report
Original Licensing
Capacity: 59
Deficiencies: 0
Jun 19, 2020
Visit Reason
The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for ProMedica Charlotte Stephenson Manor.
Findings
The facility was found to be in substantial compliance with the home for the aged public health code and administrative rules. A temporary license with a maximum capacity of 59 was recommended and issued.
Report Facts
Capacity: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Horst | Licensing Staff | Completed the licensing study and inspection |
| Russell Misiak | Area Manager | Approved the licensing study report |
| Mary Myers-Bohn | Authorized Representative/Administrator | Named as authorized representative of the facility |
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