Inspection Reports for Oasis of Clarkston
7550 Dixie Hwy, Clarkston, MI 48346, MI, 48346
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
50% 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: 15
Capacity: 30
Deficiencies: 8
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as a renewal licensing study to evaluate compliance with state regulations and determine if the facility's 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 errors, incomplete resident and employee records, inadequate heating in resident rooms, and lack of a thermometer in a resident's refrigerator. Several violations were repeat findings from a prior inspection.
Deficiencies (8)
Facility unable to provide a community TB risk assessment including residents.
Facility unable to provide a community TB risk assessment including employees; employee hired 9/18/2023 had only a TB screening dated 3/01/2023.
Medication scheduled for 8am was not administered on time and resident had left the facility before administration.
Staff did not contact physician when prescribed medication was not administered as ordered.
Facility unable to provide initial TB screening documentation for two residents.
Facility unable to provide summary of training for an employee.
Thermostats in several resident rooms read below 72 degrees Fahrenheit.
Resident's refrigerator did not have a reliable thermometer.
Report Facts
Number of residents interviewed and/or observed: 15
Facility capacity: 30
Number of staff interviewed and/or observed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Nagey | Administrator | Interviewed regarding tuberculosis screening and employee health compliance |
| Associate 1 | Employee hired 9/18/2023 with incomplete TB screening and missing summary of training | |
| Associate 2 | Observed medication administration errors and failure to notify physician |
Inspection Report
Complaint Investigation
Capacity: 30
Deficiencies: 16
Date: Mar 15, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging multiple violations including unsecured resident information, incomplete background checks and TB screenings for new hires, outdated resident service plans, and various facility maintenance and safety concerns.
Complaint Details
The complaint alleged unsecured resident information, incomplete background checks and TB screenings for new hires, outdated resident service plans, improper medication disposal, unsafe storage of furniture in public areas, malfunctioning ventilation, unmonitored water temperatures, sanitary issues in the kitchen, broken dish and ice machines, building disrepair, and lack of soap and towels in restrooms. Some allegations were substantiated while others were not.
Findings
The investigation found multiple violations including unsecured private resident information, lack of background checks and TB screenings for new hires, outdated resident service plans, improper storage of furniture in public areas, malfunctioning ventilation, unmonitored water temperatures, sanitary issues in the kitchen, broken ice machine, building disrepair, unsafe bed rails, uncleaned discharged resident rooms, missing employee records, inadequate room temperatures, missing refrigerator thermometers, and unsanitized utensils.
Deficiencies (16)
Private and confidential resident information was not kept secured.
Background checks were not consistently completed for new hires.
Resident service plans were outdated and lacked update dates.
TB screenings were not consistently completed for new hires.
Public areas were used for furniture storage, posing safety hazards.
Ceiling ventilation was not working properly in multiple areas.
Water temperatures were not being regularly checked.
Sanitary concerns in the commercial kitchen including improperly labeled and stored food.
Facility ice machine was not working and residents lacked access to ice.
The building was not in good repair with multiple maintenance issues.
Bed rails were used unsafely and against facility policy.
Resident rooms were not cleaned timely after discharge.
Employee records for two employees were missing.
Room temperatures were maintained below required levels in several resident rooms.
Thermometers were missing from three resident refrigerators.
Utensils in the kitchen were not sanitized after each use.
Report Facts
Facility capacity: 30
Inspection date: Mar 15, 2023
Employee files reviewed: 5
Employee files missing: 2
Dish machine temperature range: 120
Resident rooms with ventilation issues: 10
Resident rooms with broken toilets: 7
Resident rooms with water staining or damage: 7
Resident rooms with low temperatures: 11
Refrigerators missing thermometers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruby Mogensen | Administrator | Reported on medication disposal procedures and facility conditions |
| Mark Walker | Authorized Representative | Responded to follow-up correspondence and exit conference |
| Employee 1 | Employee file lacked background check and TB screening documentation; file missing during inspection | |
| Employee 2 | Employee file lacked background check and TB screening documentation; file missing during inspection | |
| Employee 3 | Kitchen staff who reported dish machine and ice machine issues |
Inspection Report
Complaint Investigation
Capacity: 30
Deficiencies: 1
Date: Feb 15, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging that a change in the appointed administrator was not reported to the department and that incidents were not being reported to the department.
Complaint Details
The complaint alleged that Employee 1 was the administrator since January but this was not reported, and that incidents including a resident's death and hospitalization were not reported. The complaint was anonymous and lacked specific resident names or dates.
Findings
The investigation found no violation regarding the change in administrator as the current administrator was still in place and the new administrator was in training. However, a repeat violation was established for failure to report a resident's hospitalization and incomplete incident reporting documentation.
Deficiencies (1)
Failure to report a resident's hospitalization to the department and incomplete incident report documentation.
Report Facts
Capacity: 30
Incident reports provided: 4
Incident dates not reported: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruby Mogensen | Administrator | Current administrator on file and present during inspection |
| Mark Walker | Authorized Representative | Contacted during investigation and provided information about administrator status |
Inspection Report
Original Licensing
Capacity: 30
Deficiencies: 0
Date: Jan 7, 2021
Visit Reason
The authorized representative requested an update to the licensee address for the facility.
Findings
The licensee address was updated to reflect the new address at 245 Park Avenue, 39th Floor, New York, New York 10167. The status of the license remains unchanged.
Report Facts
Capacity: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carol Krueger | Authorized Representative | Requested update to the licensee address |
| Elizabeth Gregory-Weil | Licensing Staff | Prepared the addendum report |
| Russell Misiak | Area Manager | Signed the addendum report |
Inspection Report
Original Licensing
Census: 24
Capacity: 30
Deficiencies: 0
Date: Mar 15, 2017
Visit Reason
The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for The Pines of Clarkston facility.
Findings
The study determined substantial compliance with applicable licensing statutes and administrative rules. A temporary license with a maximum capacity of 30 residents was recommended for issuance.
Report Facts
Residents present: 24
Total licensed capacity: 30
Staff employed: 20
License term duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lura Butler-Engel | Authorized Representative | Designated authorized representative of The Pines of Clarkston |
| Sherri Kio | Administrator | Administrator of The Pines of Clarkston with over three years experience |
| Linda Denniston | Licensing Staff | Conducted the licensing study and signed the report |
| Russell B. Misiak | Area Manager | Approved the licensing study report |
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