Inspection Reports for Cranberry Park of West Bloomfield
2450 Haggerty Rd, West Bloomfield Township, MI 48323, United States, MI, 48323
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Unclassified
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 1
Jul 17, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility would not allow Resident A to self-administer medications, did not treat residents with respect and kindness, and failed to provide physical therapy and proper care.
Findings
The investigation substantiated that the facility did not follow its policy or have an organized process to assess Resident A's ability to self-administer medications, resulting in removal of Resident A's medications without proper assessment. The allegation that the facility did not treat Resident A with respect and kindness was not substantiated. The facility was found to have discharged Resident A from therapy appropriately and no evidence supported the claim of neglect or mistreatment.
Complaint Details
The complaint alleged that the facility would not allow Resident A to self-administer medications, removed Resident A's medications without assessment, did not treat Resident A with respect and kindness, tried to force Resident A to take showers, threw Resident A's papers on the floor, and failed to provide physical therapy. The allegation regarding medication self-administration was substantiated; the allegation of disrespect and unkindness was not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to complete and document a medication self-administration assessment for Resident A and lack of an organized process to periodically assess ability to self-administer medications. |
Report Facts
Capacity: 53
Complaint Receipt Date: Jul 14, 2025
Investigation Initiation Date: Jul 17, 2025
Report Due Date: Sep 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Skatzka | Administrator | Interviewed regarding medication removal and facility practices |
| Rebekah Looney | Licensing Staff | Author of the Special Investigation Report |
Inspection Report
Renewal
Census: 15
Capacity: 53
Deficiencies: 8
Jun 10, 2025
Visit Reason
The inspection was conducted as a Renewal Licensing Study to assess compliance with regulatory requirements and to determine if the facility meets standards for license renewal.
Findings
The facility was found to be in non-compliance with multiple rules including inadequate staff training on Alzheimer's disease, improper use of bedside assistive devices without physician orders or proper policies, failure to update and communicate resident service plans, incomplete tuberculosis screening for employees, lack of designated shift supervisors, insufficient medication order guidance, incomplete meal census records, and lack of documented sanitation testing for kitchen utensils.
Deficiencies (8)
| Description |
|---|
| Failure to provide staff training and ongoing education on Alzheimer's disease as required by the Public Health Code. |
| Use of prohibited bedside assistive devices without physician orders or proper service plan documentation, posing safety risks to residents. |
| Failure to communicate updates of resident service plans to authorized representatives for multiple residents. |
| Employee records lacked tuberculosis testing within 10 days of hire and prior to occupational exposure for three employees. |
| Staff schedule did not identify a designated shift supervisor responsible for resident care during shifts. |
| Medication orders for PRN medications lacked sufficient guidance for staff regarding appropriate use and administration. |
| Meal census records did not include the amount of food provided, only types of food and residents served. |
| No documented testing to verify that dishwasher temperature and sanitation levels met required standards, risking utensil contamination. |
Report Facts
Number of staff interviewed and/or observed: 10
Number of residents interviewed and/or observed: 15
Capacity: 53
Number of excluded employees followed up: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Skatzka | Administrator | Interviewed regarding bedside assistive devices and communication of service plan updates |
| Jessica Rogers | Licensing Staff | Author of the report and licensing consultant |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 2
Jan 23, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident A did not receive her pain medication as prescribed.
Findings
The allegation that Resident A did not receive her pain medication as prescribed was not substantiated due to pharmacy delivery delays. However, violations were found related to staff administering narcotic medication despite Resident A reporting no pain, and failure to properly document medication administrations on multiple occasions.
Complaint Details
Complaint alleged Resident A ran out of pain medication on 12/14/24 and did not receive it until 12/18/24. The allegation was not substantiated as the delay was due to pharmacy delivery. Additional findings related to medication administration and documentation violations were substantiated.
Deficiencies (2)
| Description |
|---|
| Facility staff repeatedly administered narcotic pain medication to Resident A despite verbalizing she was not in pain. |
| Staff failed to document 51 tramadol administrations on the medication administration record (MAR) during the month of December 2024. |
Report Facts
Capacity: 53
Medication administrations not documented: 51
Medication administrations documented: 8
Medication administrations given: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Skatzka | Administrator | Named as the facility administrator during the investigation |
| Elizabeth Gregory-Weil | Licensing Staff | Conducted the inspection and authored the report |
| Hemant Shah | Authorized Representative | Named as the authorized representative of the licensee |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 1
Oct 10, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that a resident was left in a wheelchair for 24 hours and that morphine medication was administered late.
Findings
The allegation that a resident was left in a wheelchair was not substantiated based on staff and resident testimonies and documentation review. However, the allegation that morphine was given late was substantiated due to inconsistent medication administration records, despite staff and resident accounts indicating timely administration.
Complaint Details
The complaint alleged that Resident A was left in his wheelchair for 24 hours and that morphine was given late. The allegation regarding the wheelchair was not substantiated, but the morphine administration allegation was substantiated.
Deficiencies (1)
| Description |
|---|
| Medication administration records did not consistently reflect that staff initialed morphine doses as given. |
Report Facts
Capacity: 53
Complaint Receipt Date: Oct 3, 2024
Investigation Initiation Date: Oct 4, 2024
Inspection Date: Oct 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Skatzka | Administrator | Confirmed resident information and provided statements during investigation |
| Jessica Rogers | Licensing Staff | Conducted investigation and authored report |
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 2
Apr 16, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that residents did not receive meals at posted times, Resident A was fed food he was allergic to, was treated poorly, and lacked care consistent with his service plan.
Findings
The investigation found that residents were served three meals daily, though sometimes later than posted times due to staffing issues. Resident A was not fed food he was allergic to and personal preferences were accommodated. There was insufficient evidence to support claims of poor treatment or staff misconduct. However, Resident A's service plan was outdated and not fully reflective of his current care needs, and the facility failed to maintain and post menus for therapeutic diets as required, resulting in substantiated violations.
Complaint Details
The complaint alleged residents were not fed at posted times, Resident A was fed food he was allergic to, was treated poorly including family member being banned, staff were on phones and sleeping, and Resident A lacked care consistent with his service plan. Most allegations were not substantiated except for lack of care consistent with service plan and menu violations.
Deficiencies (2)
| Description |
|---|
| Resident A lacked care consistent with his service plan due to an outdated and unavailable service plan for staff. |
| Facility failed to maintain and post menus for therapeutic or special diets and did not keep previous menus as required. |
Report Facts
Facility capacity: 53
Complaint receipt date: Apr 11, 2024
Investigation initiation date: Apr 12, 2024
Inspection date: Apr 16, 2024
Exit conference date: May 8, 2024
30-day discharge notice date: Apr 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamela Skatzka | Administrator | Named as facility administrator |
| Hemant Shah | Authorized Representative | Named as authorized representative of the facility |
| Jessica Rogers | Licensing Staff | Author of the inspection report |
| LaShawnda Braxton | Interim Administrator | Interviewed during investigation regarding staff behavior and facility policies |
| Employee #1 | Named in complaint for alleged poor treatment of Resident A | |
| Employee #2 | Interviewed multiple times regarding meal service, staff conduct, and service plan updates | |
| Employee #4 | File reviewed for training and policy acknowledgements |
Inspection Report
Renewal
Deficiencies: 0
Aug 30, 2023
Visit Reason
The document serves as a notification of the renewal of the Home for the Aged license for Cranberry Park of West Bloomfield 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 the renewal of the facility's license for 12 months effective 09/10/2023.
Report Facts
License effective period: 12
Inspection Report
Complaint Investigation
Capacity: 53
Deficiencies: 2
Feb 28, 2023
Visit Reason
The inspection was conducted in response to a complaint received from Adult Protective Services alleging that Resident A left the facility through a sliding door inside her room and was missing for approximately three hours before staff were aware.
Findings
The investigation confirmed that Resident A left the facility through a sliding door that was supposed to have an audible alarm, but staff did not hear the alarm. Resident A was missing for three hours before being found safe. Additionally, the facility failed to notify the department of an administrator change within five days as required.
Complaint Details
The complaint alleged that Resident A left the facility through a sliding door inside her bedroom at 10:00 p.m. on 2/19/2023 and was missing for approximately three hours before staff noticed. The alarm on the door did not sound as expected. The complaint was substantiated.
Deficiencies (2)
| Description |
|---|
| Resident A left the facility from the sliding door inside her room without staff awareness for three hours. |
| Facility failed to notify the department of administrator change within five days. |
Report Facts
Capacity: 53
Time missing: 3
Date sliding door opened: 2157
Date last room check: 100
Administrator change notification timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyler May | Administrator | New administrator starting 4/10/2023, noted in additional findings |
| Suzy Mulka | Former Administrator | Former administrator whose last day was 4/6/2023 without notifying the department |
Inspection Report
Original Licensing
Capacity: 53
Deficiencies: 0
Mar 8, 2022
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Cranberry Park of West Bloomfield, a home for the aged facility.
Findings
The study determined substantial compliance with Public Health Code Act 368 of 1978 and administrative rules. The facility was approved for a temporary 6-month license with a maximum capacity of 53 beds, including programs for aged and Alzheimer's disease or related condition care.
Report Facts
Licensed capacity: 53
Residential units: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hemant Shah | Owner/Authorized Representative | Met on-site during inspection and involved in licensing process |
| Jenna Brown | Assistant | Met on-site during inspection and submitted revised disaster plan |
| Michelle Mihail | Administrator | Met on-site during inspection |
| Kelsey Brown | Assistant to Administrator | Met on-site during inspection |
| Bob Holmes | General Contractor | Met on-site during inspection and demonstrated repair of exhaust ventilation |
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