Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Renewal
Census: 15
Capacity: 61
Deficiencies: 8
Sep 25, 2023
Visit Reason
The inspection was conducted as a renewal licensing study for LakeHouse Kalamazoo to assess compliance with state regulations and determine if the facility meets requirements for license renewal.
Findings
The facility was found to be in non-compliance with multiple rules including employee health screenings, resident medication administration documentation, employee records, meal and food records, water temperature regulation, solid waste management, and kitchen sanitation. Violations were established in all these areas, requiring corrective action.
Deficiencies (8)
| Description |
|---|
| Employee A did not have tuberculosis screening on file within 10 days of hire and before occupational exposure. |
| Resident medication administration records for Resident A and Resident B had missing documentation and blank records, making it unclear if medications were administered as prescribed. |
| Employee A did not have a State of Michigan criminal background check consistent with MCL 333.20173. |
| No record of the preceding 3-month period of the amount of food used for the meal census. |
| Water temperature records were undated and temperatures ranged from 99°F to 120°F, outside the required 105°F to 120°F range. |
| Garbage containers in kitchen, housekeeping, laundry, and common areas lacked lids to prevent cross contamination. |
| Missing and/or incomplete dish sanitization records from June 2023 to September 2023, preventing determination if dishwasher was properly cleaned and sanitized. |
| Multiple food items in kitchen and employee lounge were not labeled with appropriate open dates, including an open Dayquil medication found in a food cabinet. |
Report Facts
Number of staff interviewed and/or observed: 8
Number of residents interviewed and/or observed: 15
Facility capacity: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Named in findings related to missing tuberculosis screening and missing criminal background check | |
| Resident A | Named in findings related to missing medication administration documentation | |
| Resident B | Named in findings related to missing medication administration documentation |
Inspection Report
Original Licensing
Capacity: 61
Deficiencies: 0
Aug 28, 2023
Visit Reason
The facility submitted an addendum to the original licensing study report to request a name change from Sojourner Place to LakeHouse Kalamazoo due to a change in the management company.
Findings
The authorized representative confirmed the management company change and requested the facility name change. The licensing staff recommended approval of the name change.
Report Facts
Capacity: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Cotton | Authorized Representative | Interviewed regarding the management company change and facility name change request |
| Kimberly Horst | Licensing Staff | Prepared and signed the addendum report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the addendum report |
Inspection Report
Complaint Investigation
Capacity: 61
Deficiencies: 1
Aug 9, 2023
Visit Reason
The investigation was initiated due to a complaint alleging that a second shift staff person was sleeping during her shift and that residents were not receiving their prescribed medications.
Findings
The investigation found no violation regarding the sleeping staff allegation due to insufficient evidence. However, a violation was established related to residents not receiving prescribed medications, including administration of discontinued medications and unavailability of some prescribed medications.
Complaint Details
The complaint alleged a second shift staff person was sleeping during her shift and that residents were not receiving their prescribed medications. The sleeping allegation was not substantiated due to lack of conclusive evidence. The medication administration allegation was substantiated with evidence of discontinued medications being administered and medications not available for Resident B.
Deficiencies (1)
| Description |
|---|
| Residents are not receiving their prescribed medications as ordered, including administration of discontinued medications and missing medications. |
Report Facts
Capacity: 61
Discontinued medication administration days: 5
Medication non-administration days: 5
Medication non-administration days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katrina Adams | Director of Health and Wellness | Interviewed regarding allegations and medication administration issues |
| Lauren Crock | Kalamazoo County APS worker | Assigned to investigate the allegations and interviewed staff and residents |
| Christina Cotton | Authorized Representative | Licensee authorized representative with whom findings were shared |
Inspection Report
Original Licensing
Capacity: 61
Deficiencies: 0
Feb 28, 2017
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Sojourner Place.
Findings
The facility was found to be in substantial compliance with the home for the aged public health code and administrative rules. The report recommends issuance of a temporary license with a maximum capacity of 61.
Report Facts
Capacity: 61
Resident apartments: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Danielczuk | Administrator | Named as the facility administrator and contacted during the licensing process |
| Lauren Wohlfert | Licensing Staff | Author of the licensing study report and recommendation |
| Russ Misiak | Area Manager | Approved the licensing recommendation |
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