Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
39% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 2
Date: Jan 29, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident A lacked care consistent with her service plan and did not receive her medications as prescribed.
Complaint Details
The complaint alleged that Resident A, who was in hospice care, experienced inadequate care leading to rapid condition worsening, was found on the floor multiple times soiled, and did not receive necessary medications resulting in severe thrush. Both allegations were substantiated.
Findings
The investigation substantiated violations related to inconsistencies between Resident A's service plan and medication administration records, incomplete documentation, and failure to administer medications as prescribed. Several falls were documented, but it could not be confirmed that Resident A was left on the floor.
Deficiencies (2)
Resident A lacked care consistent with her service plan.
Resident A did not receive her medications as prescribed.
Report Facts
Capacity: 88
Complaint Receipt Date: Jan 28, 2025
Investigation Initiation Date: Jan 29, 2025
Report Due Date: Mar 27, 2025
Medication administration errors: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alison VanRyckeghem | Authorized Representative/Administrator | Provided information during telephone interview and email correspondence related to Resident A's care |
| Jessica Rogers | Licensing Staff | Conducted investigation and authored the report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 88
Deficiencies: 5
Date: Jan 16, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident B entered Resident A's room and staff did not respond to Resident A's call light for over 20 minutes.
Complaint Details
Complaint received on 2024-12-11 alleged that on 2025-01-14 Resident B entered Resident A's room and staff did not respond to call light for over 20 minutes. The complaint was substantiated with violations found.
Findings
The investigation confirmed that Resident B entered Resident A's room and rummaged through her belongings while Resident A, who is bed bound, repeatedly pressed the call pendant without timely staff response. The facility failed to complete required safety checks and did not update service plans to reflect residents' current needs. Additional violations included failure to notify the department of administrator change and lack of monitoring regarding bed rails on Resident A's bed.
Deficiencies (5)
Resident B entered Resident A's room and staff did not respond to call light for 20 minutes.
Facility did not notify the department within 5 days of administrator change.
Resident service plans were not updated to reflect current care needs and behaviors.
Facility failed to maintain an organized program for supervision and protection, evidenced by incomplete safety checks.
Resident A had bed rails on both sides of the bed without documentation or monitoring in the service plan.
Report Facts
Facility capacity: 88
Resident census: 34
Call light response time: 20
Complaint receipt date: Jan 15, 2025
Investigation initiation date: Jan 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denell Bruyere | Administrator | Named as former administrator no longer employed as of 10/22/2024 |
| Alison Bickford | Authorized Representative | Contacted during investigation and exit conference |
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 1
Date: Aug 6, 2024
Visit Reason
The investigation was initiated due to a complaint from Adult Protective Services alleging that a resident of concern (ROC) did not receive appropriate care at Livonia Comfort Care.
Complaint Details
Complaint was received from Adult Protective Services on 07/30/2024 alleging inadequate care for the ROC. The allegation was not substantiated, but additional findings related to lack of a service plan were substantiated.
Findings
The investigation found that the ROC exhibited aggressive and combative behaviors that made care difficult, and the facility was unable to provide a service plan for the ROC. No violation was established regarding lack of care, but a violation was established for failure to have a service plan for the resident.
Deficiencies (1)
Facility did not have a written service plan for the Resident of Concern (ROC).
Report Facts
Capacity: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Denell Bruyere | Administrator | Interviewed during onsite visit regarding the Resident of Concern |
| Barbara P. Zabitz | Health Care Surveyor | Author of the Special Investigation Report |
Inspection Report
Renewal
Census: 19
Capacity: 88
Deficiencies: 7
Date: Jul 6, 2023
Visit Reason
The inspection was conducted as a Renewal Licensing Study to evaluate compliance with state regulations for license renewal of the facility.
Findings
The facility was found to be non-compliant with several administrative rules including failure to update authorized representative information, lack of timely tuberculosis screening for residents, missed medication doses without documentation, improper food labeling and storage, lack of thermometer in medication refrigerator, inconsistent sanitation testing, and unsecured hazardous materials.
Deficiencies (7)
Failure to notify department within 5 business days of change in authorized representative; current representative left on 6/16/23 with no new appointee designated.
Residents A, B, and C lacked evidence of tuberculosis screening within 12 months prior to admission.
Missed medication doses for Residents A, B, and D without documented reasons on medication administration records.
Perishable food items in walk-in refrigerator and freezer lacked labeling and proper sealing.
Medication room refrigerator lacked a reliable thermometer.
Inconsistent use of test strips to verify dish sanitation; last documented use was 4/30/23.
Hazardous and toxic materials found unsecured in assisted living and memory care kitchenettes.
Report Facts
Number of staff interviewed and/or observed: 9
Number of residents interviewed and/or observed: 19
Facility capacity: 88
Missed medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Rheingans | Authorized Representative | Named as authorized representative who left appointment on 6/16/23 |
| Sarah Molner | Administrator | Provided statement regarding sanitation test strips usage |
| Elizabeth Gregory-Weil | Licensing Consultant | Author of the inspection report and recommendation |
Inspection Report
Original Licensing
Capacity: 88
Deficiencies: 3
Date: Jan 18, 2023
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for the facility Livonia Comfort Care.
Findings
The inspection identified a few physical plant items out of compliance on 01/18/2023, which were subsequently corrected by 01/19/2023. The study determined substantial compliance with the Public Health Code and administrative rules, leading to the recommendation of a temporary 6-month license for 88 beds.
Deficiencies (3)
Exhaust ventilation in the janitor closet and nearby spa did not function.
The facility had no means to demonstrate that the multi-use utensils are sanitized.
Windows in memory care common areas do not meet compliance with the facility's program statement regarding window opening stoppers.
Report Facts
Licensed bed capacity: 88
Residential units: 71
Double occupancy units: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Megan Rheingans | Authorized Representative | Met with during on-site inspection and submitted compliance documentation. |
| Andrea Krausmann | Licensing Staff | Author of the licensing study report and recommendation. |
| Paul Mullett | Bureau of Fire Services Inspector | Completed fire safety inspection and issued certification approval. |
| Pier-George Zanoni | Health Facilities Engineering Section Engineer | Provided occupancy approval, floor plans, and room sheets. |
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