Deficiencies (last 2 years)
Deficiencies (over 2 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
38% occupied
Based on a September 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 23
Capacity: 61
Deficiencies: 5
Sep 27, 2023
Visit Reason
The inspection was conducted as a renewal licensing study to assess compliance with state regulations and determine if the facility license should be renewed.
Findings
The facility was found to be in non-compliance with multiple rules including tuberculosis screening for residents and employees, medication administration documentation, meal and food record maintenance, and safe storage of hazardous materials. Violations were established for each of these areas.
Deficiencies (5)
| Description |
|---|
| Resident tuberculosis screening was missing or not completed within 12 months before admission. |
| Employee tuberculosis screening was not completed before occupational exposure as required. |
| Medication administration record for Resident A was incomplete and inconsistent with narcotic medication log. |
| No record of the preceding 3-month period of the amount of food used for the meal census. |
| Industrial chemicals were stored in an accessible location posing a risk to residents. |
Report Facts
Number of staff interviewed and/or observed: 8
Number of residents interviewed and/or observed: 23
Facility capacity: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abigail Mulholland | Administrator/Licensee Designee | Named as Administrator/Licensee Designee in identifying information |
| Christina Cotton | Authorized Representative | Named as Authorized Representative in identifying information |
| Allizette Newton | Mentioned as excluded employee followed up due to exclusion notice |
Inspection Report
Complaint Investigation
Capacity: 61
Deficiencies: 3
Aug 22, 2023
Visit Reason
The investigation was initiated due to a complaint alleging the facility is not fully staffed, medications are not administered, and residents fall. The complaint was investigated under a special investigation report.
Findings
The investigation found violations related to residents being left wet and unattended, employees sleeping while working, and failure to notify the department of a facility name change. The facility roof leak was addressed promptly and was not a violation. The facility was found equipped to care for residents.
Complaint Details
The complaint alleged the facility is not fully staffed, medications are not administered, and residents fall. Specific allegations included residents being left wet and not cared for, employees sleeping while working, and a leaking roof. Some allegations were substantiated, including residents left wet and unattended, employees sleeping on duty, and failure to notify the department of a name change.
Deficiencies (3)
| Description |
|---|
| Residents are left wet and not attended to. |
| Employees sleep while working. |
| Failure to provide written notice to the department within 5 business days of facility name change. |
Report Facts
Capacity: 61
Written warnings issued: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abigail Mulholland | Administrator | Provided statements regarding facility care and staffing |
| Kimberly Horst | Licensing Staff | Author of the inspection report |
| SP6 | Third shift worker | Employee caught sleeping while working and issued warnings |
| SP7 | Third shift worker | Reported witnessing SP6 sleeping on the job |
| SP9 | Staff person | Reported residents left in bed covered in urine and feces and confirmed SP6 sleeping |
Inspection Report
Original Licensing
Capacity: 61
Deficiencies: 0
Aug 14, 2023
Visit Reason
The facility is requesting a name change from Bowman Place to LakeHouse Three Rivers as part of the original licensing study addendum.
Findings
An interview with the authorized representative revealed a change in the management company and a request to change the facility name. The recommendation is to approve the name change to LakeHouse Three Rivers.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christina Cotton | Authorized Representative | Named in relation to the facility name change and management company change. |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 61
Deficiencies: 1
Jul 11, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging a resident fall without interventions, insufficient staffing, incomplete medication administration records, residents not receiving showers, and facility cleanliness issues.
Findings
The investigation found no violations regarding resident falls, staffing sufficiency, shower provision, or facility cleanliness. However, a violation was established for incomplete medication administration records where multiple instances of missing initials on medication logs were documented.
Complaint Details
Complaint received on 2023-07-06 alleging resident fall without interventions, insufficient staffing including staff sleeping on the job, incomplete MARs, residents not receiving showers, and facility dirtiness. Investigation did not substantiate most allegations except for incomplete MAR documentation.
Deficiencies (1)
| Description |
|---|
| Medication Administration Record (MAR) incomplete with multiple instances of missing initials for administered medications. |
Report Facts
Facility capacity: 61
Resident census: 28
Falls in June: 6
Resident MARs reviewed: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abigail Mulholland | Administrator | Interviewed regarding resident falls, staffing, and facility operations |
| Kimberly Horst | Licensing Staff | Author of the Special Investigation Report |
Inspection Report
Original Licensing
Capacity: 61
Deficiencies: 0
Mar 22, 2017
Visit Reason
The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Bowman Place, a home for the aged facility.
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brad Mason | Administrator | Named as the facility administrator |
| Jeffrey Floyd | Authorized Representative | Named as the authorized representative of the facility |
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