Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
The inspection was conducted following an allegation that the facility failed to effectively manage and assess pain for a resident who had a fall with injury resulting in ongoing pain.
Complaint Details
The complaint investigation was substantiated based on findings that the facility did not effectively manage and assess pain for resident R901 following a fall on 3/4/25, resulting in ongoing pain and eventual hospital admission for fractures.
Findings
The facility failed to properly assess and ensure effective pain management for one resident (R901) after a fall on 3/4/25. Despite documented pain scores and administration of PRN pain medications, the care plan was not updated post-fall, and there was no evidence of scheduled pain management. The resident was eventually transferred to a hospital where fractures were identified. Facility staff interviews and record reviews confirmed inconsistent pain management and communication issues with the resident's family.
Deficiencies (1)
Failure to properly assess and ensure effective pain management for a resident after a fall with injury.
Report Facts
Pain scores documented: 10
Dates of pain medication administration: 22
Date of fall: Mar 4, 2025
Date of hospital transfer: Mar 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UM B | Unit Manager | Interviewed family member and documented communication regarding medication and pain management |
| NS C | Nurse Supervisor | Communicated with family member about medication administration |
| LPN G | Licensed Practical Nurse | Documented resident's groaning and PRN medication administration |
| LPN H | Licensed Practical Nurse | Documented resident yelling out and PRN pain medication administration |
| LPN E | Licensed Practical Nurse | Documented resident's pain and communication with family about hospital transfer |
| MD D | Medical Director | Ordered x-rays following resident's fall |
| NHA | Nursing Home Administrator | Interviewed regarding resident's pain and hospital findings |
| DON | Director of Nursing | Interviewed regarding resident's pain management and fall |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 17, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to provide timely mattress replacement for a resident and failure to provide nail care for dependent residents.
Complaint Details
The complaint investigation found substantiated deficiencies related to mattress replacement delays and inadequate nail care for residents R45, R5, and R66.
Findings
The facility failed to provide a mattress in a timely manner for one resident, causing discomfort and back pain, and failed to provide nail care for two dependent residents, resulting in unmet care needs. Staff did not follow proper protocols for documenting mattress replacement requests and nail care was inconsistently provided.
Deficiencies (2)
Failed to provide a mattress in a timely manner for one resident, resulting in disturbed sleep and back pain.
Failed to provide nail care for two dependent residents, resulting in unmet care needs.
Report Facts
Residents reviewed for ADLs: 5
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aid A | Certified Nursing Aid | Confirmed staff should have written order for new mattress in TELS |
| Maintenance staff B | Maintenance Staff | Confirmed mattress had dip and order was not placed until resident verbalized frustration |
| Director of Nursing | Director of Nursing | Confirmed staff should have documented mattress condition and stated nail trims should occur on shower days |
| Certified Nurse Assistance C | Certified Nurse Assistant | Interviewed regarding nail trims and stated they should occur on shower days |
| Certified Nurse Assistance D | Certified Nurse Assistant | Interviewed regarding nail trims and stated they should occur on shower days |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 14, 2024
Visit Reason
The inspection was conducted following complaints regarding residents not being properly dressed in the dining room and a privacy violation involving a resident's video circulating on social media.
Complaint Details
The complaint involved residents not being properly dressed in the dining room and a video of resident R66 circulating on social media without consent. The video showed a CNA laughing while assisting the resident with eating. The facility investigated, suspended, and terminated the involved employee. The family confirmed the video was a violation of privacy rights.
Findings
The facility failed to maintain the dignity of five residents by not ensuring they were properly dressed for meals, resulting in residents expressing frustration and discomfort. Additionally, the facility failed to maintain privacy for one resident when a staff member posted a video of the resident on social media without consent, leading to staff termination.
Deficiencies (2)
Failure to honor residents' rights to a dignified existence, self-determination, communication, and to exercise their rights, specifically related to residents not being properly dressed for meals.
Failure to keep residents' personal and medical records private and confidential, resulting in exposure of a resident on social media via video and text message.
Report Facts
Residents reviewed for dignity: 6
Residents affected by dignity deficiency: 5
Residents reviewed for privacy: 2
Residents affected by privacy deficiency: 1
BIMS scores: 11
BIMS scores: 15
BIMS scores: 7
BIMS scores: 3
Clothes return timeframe: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nursing Assistant | Reported clothes provided to resident R54 came from lost and found. |
| CNA H | Certified Nursing Assistant | Interviewed regarding residents not being properly dressed in the dining room. |
| CNA L | Certified Nursing Assistant | Posted a video of resident R66 on social media and was terminated for privacy violation. |
| Laundry Aide B | Laundry Aide | Reported personal clothes are returned to residents within 72 hours. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding residents being properly dressed in the dining room for meals. |
| Administrator P | Former Administrator | Reviewed the video of resident R66, substantiated the violation, suspended and terminated the involved employee. |
| RDO K | Regional Director of Operation | Interviewed regarding the social media video incident and staff training on resident rights. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 11, 2024
Visit Reason
The inspection was conducted following complaints regarding residents not being properly dressed in the dining room, a privacy violation involving a resident's video posted on social media, and concerns about infection control practices.
Complaint Details
The complaint investigation included reports of residents not being properly dressed in the dining room, a video of resident R66 posted on social media without consent, and infection control concerns. The video was substantiated as a privacy violation, leading to termination of the involved employee. The facility acknowledged the issues and policies related to dignity, privacy, and infection control.
Findings
The facility failed to maintain residents' dignity by not ensuring they were properly dressed for meals, failed to protect a resident's privacy by allowing a video of the resident to be posted on social media, and failed to implement proper infection prevention and control practices including hand hygiene and proper storage of ice scoopers.
Deficiencies (3)
Failure to honor residents' rights to dignity and self-determination by not dressing residents properly for meals, resulting in residents wearing gowns and expressing discomfort and frustration.
Failure to maintain privacy for one resident resulting in exposure on social media via video and text message.
Failure to provide and implement an infection prevention and control program, including improper hand hygiene and improper storage of ice scoopers, resulting in potential spread of microorganisms.
Report Facts
BIMS score: 11
BIMS score: 15
BIMS score: 7
BIMS score: 3
BIMS score: 3
BIMS score: 6
Timeframe: 72
Date: Feb 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nursing Assistant | Reported clothes provided to resident R54 came from lost and found. |
| CNA H | Certified Nursing Assistant | Interviewed regarding residents not being properly dressed in the dining room. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding residents being properly dressed and infection control practices. |
| Laundry Aide B | Laundry Aide | Reported personal clothes are returned to residents in 72 hours. |
| CNA L | Certified Nursing Assistant | Involved in posting a video of resident R66 on social media; employee was terminated. |
| Staff Development Coordinator A | Staff Development Coordinator | Observed failing to perform hand hygiene before and after glove use. |
| Nurse Aide C | Nurse Aide | Observed preparing ice water with uncovered ice scooper. |
| Nurse D | Nurse | Observed preparing ice water with uncovered ice scooper. |
| Regional Director of Operation K | Regional Director of Operation | Interviewed regarding social media privacy violation incident. |
| Administrator P | Administrator | Reviewed video of privacy violation, suspended and terminated involved employee. |
Inspection Report
Routine
Census: 91
Deficiencies: 15
Date: Feb 8, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, and comfortable environment for residents, staff, and the public, focusing on physical plant cleanliness and maintenance.
Findings
The facility failed to effectively clean and maintain the physical plant, affecting 91 residents, with issues including damaged caulking, soiled flooring, non-functional lighting, loose grab bars, leaking spa tub jets, corroded equipment, and soiled ventilation grills, increasing the risk of cross-contamination and bacterial harborage.
Deficiencies (15)
The spa tub leaks and has been out of service for approximately 1-1.5 weeks.
Commode base caulking was observed etched, cracked, stained, separated.
Janitor closet flooring soiled with accumulated and encrusted dust and dirt deposits; disorganized storage of miscellaneous items.
Three of six overhead fluorescent light bulbs non-functional; ventilation grill soiled; commode grab bar loose-to-mount; spa tub water jets damaged and leaking; handheld wand assembly loose; water supply valve semi-seized.
Microwave oven interior etched, scored, corroded, particulate.
Janitor closet flooring soiled with dust, dirt, grime; extremely frayed broom resting on floor.
Laboratory ventilation grill heavily soiled with dust and dirt deposits.
Mop sink basin heavily soiled with accumulated and encrusted dust/dirt deposits.
One of two shower stall grab bars loose-to-mount.
Staff locker room floor metal heating duct cover heavily corroded and particulate.
Shower room water pressure low; wand assembly mineralized with calcium and lime deposits; missing atmospheric vacuum breaker; hand sink loose-to-mount; gap between hand sink basin and wall 0.5-1.0 inches.
Resident rooms with soiled hand sinks adjacent to faucet perimeter and commode base caulking etched, scored, stained, particulate.
Overbed light plastic protective cover cracked and broken; overbed light pull string extensions missing; fluorescent light bulb non-functional.
Hand sink basin draining slowly; restroom over sink light assembly non-functional; hand sink basin support leg resting against restroom wall.
Commode base caulking etched, scored, stained, particulate; hand sinks soiled adjacent to faucet perimeter; acoustical ceiling tile stained from previous moisture leak.
Report Facts
Residents Affected: 91
Fluorescent light bulbs non-functional: 3
Spa tub water jets damaged: 2
Shower stall grab bars loose: 1
Gap between hand sink basin and wall: 0.5
Gap between hand sink basin and wall: 1
Days reviewed for work orders: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager H | Licensed Practical Nurse (LPN) Unit Manager | Interviewed regarding the 2007 ARJO Spa Tub leaking and out of service |
| Director of Maintenance K | Director of Maintenance | Conducted environmental tours, noted deficiencies, and discussed work order system |
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