Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 2
Aug 21, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging emotional abuse of residents by staff at Sunrise Of West Bloomfield.
Findings
The investigation confirmed that residents were emotionally abused by staff, including teasing and antagonizing Resident A and an incident involving Employee 7 and Resident B. Additionally, the facility failed to complete an incident report related to the emotional abuse incident.
Complaint Details
The complaint alleged that Resident A was teased by staff and Resident B was emotionally abused by the administrator on 7/8/24. The complaint was substantiated with violations established.
Deficiencies (2)
| Description |
|---|
| Facility staff failed to treat Resident A with dignity and respect consistent with public health code by antagonizing her, causing emotional distress on 4/20/24. |
| The licensee could not demonstrate that an incident report was completed on the 4/20/24 incident involving Resident A, and corrective measures could not be confirmed or evaluated. |
Report Facts
Capacity: 70
Complaint Receipt Date: Aug 6, 2024
Investigation Initiation Date: Aug 7, 2024
Inspection Date: Aug 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Pleaugh | Administrator and Authorized Representative | Interviewed regarding allegations and incidents involving Resident A and Resident B |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 70
Deficiencies: 2
Aug 21, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging neglect of Resident C, contributing to his death, and concerns about understaffing at the facility.
Findings
The investigation confirmed neglect of Resident C, as his service plan was not followed leading to a fall and injury contributing to his death. The allegation of understaffing was not substantiated, but the facility was found to have violations related to inaccurate staff schedules.
Complaint Details
Complaint alleged neglect of Resident C contributing to his death due to staff negligence and insufficient monitoring. The complaint also alleged understaffing but lacked specific examples or dates. Neglect violation was established; understaffing violation was not.
Deficiencies (2)
| Description |
|---|
| Resident C’s service plan was not followed on 7/9/24, resulting in a fall with injury. |
| Facility schedules were not updated on three occasions to accurately reflect care and med passing staff present. |
Report Facts
Residents present: 31
Total licensed capacity: 70
Falls documented: 2
Staffing levels: 4
Staffing levels: 3
Dates with inaccurate schedules: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Pleaugh | Administrator and Authorized Representative | Interviewed onsite regarding Resident C and staffing; provided documentation and staffing information |
| Elizabeth Gregory-Weil | Licensing Staff | Author of the Special Investigation Report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report |
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 2
Feb 14, 2024
Visit Reason
The investigation was initiated due to a complaint alleging that Resident A sustained injuries from a fall that was not documented or reported, resulting in delayed medical attention and subsequent death.
Findings
The investigation found that Resident A, who required two-person assistance for transfers, sustained a broken femur that was not reported or documented as a fall. Staff interviews and record reviews revealed no knowledge of the fall, and the service plan lacked adequate information regarding the use of a Hoyer lift for transfers. Violations were established related to failure to protect the resident and inadequate service planning.
Complaint Details
Complaint alleged Resident A sustained injuries from a fall on 2/6/2024 that was not documented or reported, resulting in delayed medical attention and death on 2/8/2024. The complaint was substantiated with violations established.
Deficiencies (2)
| Description |
|---|
| Failure to protect Resident A from harm while under facility care as a fall was not reported or documented. |
| Service plan did not adequately reflect the resident's needs for two-person assistance and use of a Hoyer lift for transfers. |
Report Facts
Facility capacity: 70
Complaint receipt date: Feb 12, 2024
Investigation initiation date: Feb 13, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber James | Former Administrator | Interviewed during onsite inspection regarding Resident A's fall and investigation |
| Kristy Britton | Administrator/Authorized Representative | Newly appointed administrator as of report date |
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 1
Nov 8, 2023
Visit Reason
The investigation was initiated due to allegations that two staff assaulted and stole money from Resident A at Sunrise Of West Bloomfield.
Findings
The investigation found that the allegations were unsubstantiated and considered hearsay. Resident A's funds were properly documented and managed, but the facility was found to be holding resident funds without a surety bond approved by the department, which is a violation.
Complaint Details
The complaint alleged that two staff assaulted and stole $180 from Resident A. The complainant was not identified and later stated the allegations were hearsay. Interviews with staff, witnesses, and family members did not substantiate the allegations.
Deficiencies (1)
| Description |
|---|
| Facility is currently holding resident funds without a surety bond approved by the department. |
Report Facts
Resident funds amount: 180
Facility capacity: 70
Corrective action plan due days: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber James | Authorized Representative/Administrator | Interviewed regarding the complaint and facility operations. |
| Patrick Pantloni | Activity Director | Provided documentation and information during the investigation. |
| Andrea Krausmann | Licensing Staff | Author of the Special Investigation Report. |
Inspection Report
Complaint Investigation
Capacity: 70
Deficiencies: 3
Nov 8, 2023
Visit Reason
The investigation was initiated due to complaints that visitors and police were unable to enter the facility and reach staff by telephone, and that an elderly male resident was undressed on the balcony without staff assistance.
Findings
The investigation found that the facility's phone and doorbell system routed calls to a single memory care staff who was often busy, resulting in delayed responses. Staff failed to immediately assist a resident who was undressed on the balcony, and Resident A's service plan was not updated to address repeated calls to staff and emergency services.
Complaint Details
The complaint was substantiated. Violations were established regarding staff unavailability to respond to visitors and police, failure to assist a resident on the balcony, and failure to update a resident's service plan.
Deficiencies (3)
| Description |
|---|
| Failure to maintain an organized program of protection, supervision, and assistance for residents after concierge leaves and phone calls are routed to a single busy staff member. |
| Failure to treat a resident with dignity and attend to personal needs, including protection and safety, when a resident was undressed on the balcony and staff did not immediately assist. |
| Failure to update Resident A's service plan to address repeated phone calls to staff, police, and EMS. |
Report Facts
Capacity: 70
Complaint Receipt Date: Nov 6, 2023
Investigation Initiation Date: Nov 6, 2023
Report Due Date: Jan 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber James | Administrator and Authorized Representative | Interviewed multiple times and involved in investigation and exit conference |
| Patrick Pantloni | Activity Director | Filled in for administrator during inspection |
Inspection Report
Renewal
Census: 21
Capacity: 70
Deficiencies: 4
May 10, 2023
Visit Reason
The inspection was conducted as a renewal licensing study for the facility to assess compliance with regulatory requirements and to determine if the license should be renewed.
Findings
The facility was found to be non-compliant with several administrative rules including failure to notify residents of a change in ownership, multiple medication administration errors and documentation issues, and deficiencies in kitchen and dietary practices such as improper labeling of food items and missing thermometers in refrigerators and freezers.
Deficiencies (4)
| Description |
|---|
| Failure to notify residents of change in ownership affecting resident admission contracts. |
| Multiple medication administration errors including missed doses, documentation errors, and lack of physician notification for refused medications. |
| Perishable food items in kitchen lacked proper labeling, dating, and sealing. |
| Missing reliable thermometers in refrigerators and freezers in occupied apartments #118, 123, 218, and 222. |
Report Facts
Number of staff interviewed and/or observed: 17
Number of residents interviewed and/or observed: 21
Facility capacity: 70
Number of occupied apartments missing thermometers: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amber James | Authorized Representative and Administrator | Reported on medication administration documentation errors and facility ownership change |
| Elizabeth Gregory-Weil | Licensing Consultant | Author of the inspection report and recommendation |
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