Inspection Reports for Symphony Linden
202 S Bridge St, Linden, MI 48451, United States, MI, 48451
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
246% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
52 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 52
Deficiencies: 15
Date: Sep 9, 2025
Visit Reason
The inspection was conducted based on observation, interview, and record review to assess compliance with resident rights, care planning, infection control, medication management, environmental safety, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate care planning, incomplete infection surveillance, improper medication management, environmental cleanliness issues, lack of proper vaccination documentation, and unsafe water system backflow prevention.
Deficiencies (15)
Failed to ensure residents were treated in a respectful and dignified manner, resulting in missing items not replaced timely and difficulties with after-hours reentry.
Failed to ensure Code Status was accurately documented and accessible in the medical record Care Plan for one resident, resulting in potential miscommunication.
Failed to provide a clean, comfortable and homelike environment, resulting in unclean resident rooms, bathrooms, and common areas with resident dissatisfaction and infection control concerns.
Failed to ensure PASARR assessments were completed yearly and posted into residents' clinical records for two residents.
Failed to develop and revise comprehensive care plans for four residents, resulting in lack of resident-specific interventions.
Failed to provide appropriate wound treatment and hospice orders for three residents, resulting in missing treatments and lack of hospice documentation.
Failed to provide adequate supervision and revise care plan to prevent falls for one resident, resulting in falls and injuries.
Failed to ensure consents were signed and behavior monitoring was provided for psychotropic medications for two residents.
Failed to ensure medications and supplements were labeled, stored, and disposed of properly, resulting in expired and unlabeled medications found in medication rooms and carts.
Failed to properly dispose of waste and maintain dumpster area, resulting in presence of insects and rodents.
Failed to have an active plan for reducing risk of legionella and other opportunistic pathogens in premise plumbing, complete routine infection surveillance, and ensure appropriate use of personal protective equipment.
Failed to implement a program that monitors antibiotic use, including resistance patterns and infection trends.
Failed to develop and implement policies and procedures for influenza and pneumococcal vaccinations, including consistent assessment, education, and documentation.
Failed to educate residents and staff on COVID-19 vaccination, offer vaccine after education, and properly document vaccination status.
Failed to ensure appropriate backflow prevention was installed on cross connections, increasing risk of water supply contamination.
Report Facts
Residents affected: 52
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 2
Expired supplements: 3
Expired medication: 1
Unlabeled medications: 2
Loose pills: 1
Infection Surveillance months missing: 8
Fall incidents: 2
Fall incident: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Nurse | Cared for Resident #6 and discussed wound treatment |
| Social Services Manager E | Social Services Manager | Interviewed about Code Status, hospice services, psychotropic medications, and behavior monitoring |
| Administrator | Facility Administrator | Admitted ongoing phone issues and lack of after-hours coverage |
| Activities Director L | Activities Director | Handled missing items grievance process |
| Ombudsman K | Ombudsman | Reported missing clothes issue for Resident #22 |
| Infection Preventionist H | Infection Preventionist | Interviewed about infection surveillance and infection control program |
| Transitional Care Coordinator E | Transitional Care Coordinator | Interviewed about psychotropic medication monitoring and hospice orders |
| Licensed Practical Nurse B | LPN | Verified expired medication disposal |
| Licensed Practical Nurse C | LPN | Verified expired medication disposal |
| Registered Nurse C | RN | Verified unlabeled medications in medication cart |
| Nurse A | LPN | Observed not applying proper PPE during medication administration |
| Nurse H | Nurse | Interviewed about Resident #7 fall and supervision |
| Nurse G | Staff | Reported Resident #7 fall incident |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 5
Date: Sep 9, 2025
Visit Reason
The inspection was conducted based on complaints and concerns raised by residents and family members regarding residents' rights, personal property issues, cleanliness, infection control, care planning, and safety in the facility.
Complaint Details
The investigation was triggered by complaints from residents and family members about missing personal items, difficulty with visitation and reentry after hours, unclean living environments, infection control concerns, incomplete care plans, and plumbing safety hazards. Some complaints were substantiated, including ongoing issues with missing items, uncleanliness, and infection risks.
Findings
The facility failed to ensure residents were treated with dignity and respect, maintain a clean and safe environment, implement effective infection prevention and control, develop comprehensive care plans, and ensure proper backflow prevention in plumbing. Issues included missing resident items not replaced timely, unclean resident rooms and bathrooms, inadequate infection surveillance, improper PPE use, incomplete care plans for several residents, and plumbing cross-connection hazards.
Deficiencies (5)
Failed to honor residents' rights to dignified existence and communication, including unresolved missing personal items and difficulty reentering the building after hours.
Failed to provide a safe, clean, comfortable, and homelike environment; multiple resident rooms and bathrooms were unclean with odors, rust stains, soiled toilets, and clutter.
Failed to develop and revise comprehensive, resident-centered care plans for multiple residents, resulting in lack of specific interventions for falls, infections, and skin integrity.
Failed to provide and implement an effective infection prevention and control program, including incomplete infection surveillance, inadequate environmental rounds, and improper PPE use.
Failed to ensure appropriate backflow prevention on plumbing cross connections, increasing risk of water supply contamination.
Report Facts
Facility census: 52
Missing clothes reimbursement: 23
Resident falls: 2
Housekeeping staff: 3
Chlorine residual levels: 116.2
Chlorine residual levels: 111.2
Chlorine residual levels: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Observed not applying proper PPE during medication administration for Resident #70 |
| Administrator | Admitted ongoing phone issues and lack of after-hours staff coverage | |
| Social Services Director | Confirmed resident had court-appointed guardian and visitation preapproval requirements | |
| Activities Director L | Activities Director | Handled missing items and grievance forms for residents |
| Infection Preventionist H | Infection Preventionist | Reported incomplete infection surveillance and environmental cleanliness issues |
| Housekeeping Supervisor F | Housekeeping Supervisor | Acknowledged cleaning issues and staffing levels |
| Housekeeper I | Housekeeper | Interviewed about cleaning practices and products used |
Inspection Report
Renewal
Census: 10
Capacity: 20
Deficiencies: 3
Date: May 29, 2025
Visit Reason
The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing rules and determine if the facility's license should be renewed.
Findings
The facility was found to be non-compliant with several rules including failure to conduct required fire drills quarterly during all shifts, a large hole in the laundry room wall, and lack of operational ventilation fans in several resident bathrooms without windows.
Deficiencies (3)
Failure to produce documentation of fire drills conducted during required times (April 2023 – December 2023, January 2024 – March 2024, January 2025, May 2025).
Large hole in the laundry room wall near the dryer vent, violating maintenance of premises requirements.
Several resident bathrooms without operational ventilation fans, violating bathroom ventilation requirements.
Report Facts
Number of staff interviewed and/or observed: 3
Number of residents interviewed and/or observed: 10
Facility capacity: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Edwards | Administrator | Named as Licensee/Licensee Designee and Administrator |
| Susan Hutchinson | Licensing Consultant | Author of the inspection report and recommendation |
Inspection Report
Deficiencies: 3
Date: Jan 23, 2025
Visit Reason
The inspection was conducted based on intake numbers MI00149339 and MI00149518 to evaluate complaints regarding the cleanliness of residents' rooms and adequacy of linen supplies.
Findings
The facility failed to provide a clean, comfortable, and homelike environment by not ensuring residents' rooms were clean and lacking sufficient clean linen, resulting in an unclean physical environment and resident dissatisfaction. Observations included soiled bathrooms, insufficient clean towels and washcloths, and housekeeping staffing issues.
Deficiencies (3)
Residents' rooms were not clean, including soiled toilets and floors with stains and debris.
Insufficient clean towels and washcloths available for resident use across multiple hallways.
Lack of housekeeping and linen policies provided upon request.
Report Facts
Number of clean towels available: 1
Number of clean washcloths available: 1
Date of order form for new towels and washcloths: Jan 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide E | Nurse Aide | Observed sorting resident's clothes during inspection |
| Director of Nursing | Director of Nursing | Provided information about linen storage and cleaning observations |
| Administrator | Administrator | Interviewed about lack of clean towels and washcloths and staffing issues |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 3, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure that the bladder scanner was in good repair, which impacted clinical assessment of residents with urinary retention.
Complaint Details
The complaint investigation found that the bladder scanner was broken and unavailable during a trial void for Resident #500, leading to delayed care and complications. The facility staff did not report the broken equipment timely, and the administrator did not arrange for repair or replacement. Resident #500 was sent to the emergency room after unsuccessful catheter reinsertion attempts. The complaint was substantiated.
Findings
The facility failed to maintain the bladder scanner in working order, resulting in delayed urinary care for Resident #500, who experienced urinary retention, severe abdominal pain, and complications due to inability to properly assess bladder volume. Attempts to reinsert a Foley catheter were unsuccessful, leading to emergency room transfer. The bladder scanner was broken since before 11/16/24 and was not repaired or replaced despite awareness.
Deficiencies (1)
Failure to keep the bladder scanner in good repair to clinically assess residents with urinary retention.
Report Facts
Residents with indwelling catheters: 4
Residents reviewed with indwelling catheters: 3
Bladder scan threshold: 350
Date of survey completion: Dec 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Interviewed nurse who reported the broken bladder scanner and attempted catheter reinsertion. |
| Nurse Practitioner B | Nurse Practitioner | Interviewed NP who ordered catheter reinsertion and commented on bleeding and complications. |
| Director of Nursing | Director of Nursing | Interviewed DON who admitted unawareness of broken scanner and described events. |
| Nurse C | Nurse | Interviewed nurse who recalled catheter removal and problems reinserting due to broken scanner. |
| Administrator | Administrator | Interviewed administrator who acknowledged broken equipment and lack of repair or replacement. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 13
Date: Aug 22, 2024
Visit Reason
The inspection was conducted based on complaint intakes regarding resident care concerns including call light response times, resident dignity, abuse allegations, medication administration, and facility environment.
Complaint Details
This investigation pertains to multiple complaint intake numbers including MI00134717, MI00140086, MI00143075, MI00136526, MI00133932, and MI00144896. Complaints involved resident dignity, abuse, medication errors, nutrition, respiratory care, staffing, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to protect from abuse, incomplete incident investigations, inadequate care planning, medication errors, improper respiratory equipment care, unsafe environment, and incomplete nurse staffing records.
Deficiencies (13)
Failure to ensure residents were treated with dignity and call lights were answered timely, resulting in resident frustration and embarrassment.
Failure to protect Resident #59 from sexual abuse by another resident.
Failure to retain complete documentation of injury after fall investigation for Resident #56.
Failure to develop and implement person-centered baseline care plans within 48 hours for Residents #307 and #308.
Failure to develop and implement a comprehensive care plan for Resident #23's CPAP machine use and maintenance.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Resident #39, resulting in four facility-acquired pressure ulcers.
Failure to ensure timely assessments and monitoring of nutritional needs for Residents #307 and #308, resulting in inadequate nutrition care.
Failure to ensure proper storage, cleaning, and labeling of oxygen/respiratory equipment for Residents #9, #23, and #34.
Failure to ensure physician orders and facility policy were followed for enteral feeding for Resident #39, resulting in incomplete feeding and lack of documentation.
Failure to post complete and accurate nurse staffing information daily, with missing and incomplete staffing reports.
Failure to ensure medication carts and treatment carts were secured, medications properly labeled, and topical treatments stored separately from oral medications.
Failure to ensure medications were available and administered timely for Residents #30 and #103, resulting in medication errors and potential adverse effects.
Failure to ensure proper communication and documentation of hospice services for Resident #39, resulting in absence of progress notes.
Report Facts
Facility census: 55
Medication administration opportunities observed: 32
Medication errors observed: 2
Medication error rate: 6.25
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 1
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 3
Braden Score: 14
Resident weight: 112.8
Resident #307 pain rating: 10
Resident #307 pain rating: 5
Resident #30 BIMS score: 15
Resident #9 BIMS score: 5
Resident #23 BIMS score: 12
Resident #39 BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse K | Nurse | Involved in medication administration errors and medication availability issues for Residents #30 and #103 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including medication errors, respiratory care, hospice communication, and staffing |
| Unit Manager E | Unit Manager | Interviewed regarding resident care concerns and dialysis care |
| CNA J | Certified Nursing Assistant | Witnessed sexual abuse incident involving Resident #59 |
| Dietary Manager H | Dietary Manager | Interviewed regarding nutrition assessments and dietary orders for Residents #307 and #308 |
| Registered Dietitian I | Registered Dietitian | Interviewed regarding dietary assessments and nutrition care for Residents #307 and #308 |
| Therapy Program Manager Q | Therapy Program Manager | Interviewed regarding restorative therapy program and Resident #25's therapy discharge |
| Nurse O | MDS Program Director | Interviewed regarding care planning for Resident #23's CPAP machine |
| RN E | Registered Nurse | Observed leaving medication cart unlocked in 300 Hall |
| Scheduler D | Scheduler | Responsible for starting nurse staffing forms |
| Receptionist | Receptionist | Responsible for completing nurse staffing forms on days Scheduler D is off |
| Maintenance Director M | Maintenance Director | Interviewed regarding open furnace closet door and kitchen drain issues |
| Social Services Manager G | Social Services Manager | Interviewed regarding Resident #307's discharge to hospice |
| Nurse A | Registered Nurse | Interviewed regarding oxygen tubing labeling and resident oxygen use |
| Nurse N | Nurse | Interviewed regarding medication cart labeling and storage |
| Administrator | Administrator | Notified of medication errors and medication cart security issues |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 11
Date: Aug 21, 2024
Visit Reason
The inspection was conducted based on multiple complaint intakes regarding resident care, abuse, neglect, medication errors, and facility conditions.
Complaint Details
This inspection pertains to multiple complaint intake numbers MI00134717, MI00140086, MI00143075, MI00133932, MI00136526, MI00144896.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to protect from abuse, incomplete incident investigations, inadequate pressure ulcer care, poor nutrition monitoring, improper enteral feeding administration, insufficient pain management, medication errors exceeding 5%, lack of annual competency training for CNAs, failure to maintain proper hospice documentation, and unsafe and unsanitary environmental conditions.
Deficiencies (11)
Failure to ensure residents were treated with dignity and respect, including timely response to call lights and staff talking on personal phones during care.
Failure to protect Resident #59 from sexual abuse by Resident #309.
Failure to retain complete documentation of injury after fall investigation for Resident #56.
Failure to implement interventions to prevent development of pressure ulcers for Resident #39.
Failure to ensure timely nutritional assessments and monitoring for Residents #307 and #308.
Failure to follow physician orders and facility policy for enteral feeding for Resident #39, resulting in incomplete feeding and lack of documentation.
Failure to assess, monitor, and provide pain management for Resident #307, resulting in unrelieved pain and frustration.
Failure to maintain annual competency training of 12 hours for three CNAs.
Failure to ensure medications were available and administered timely for Residents #30 and #103, resulting in medication errors.
Failure to ensure proper communication and documentation of hospice services for Resident #39.
Failure to maintain a safe, clean, and sanitary environment in resident care and kitchen areas, including issues with drains, leaks, odors, and housekeeping.
Report Facts
Facility census: 55
Medication administration opportunities observed: 32
Medication errors observed: 2
Medication error rate: 6.25
CNA in-service training hours: 7.58
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 2.5
Braden Score: 14
Resident weight: 112.8
Blood sugar: 148
Blood sugar: 182
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse K | Involved in medication administration errors and interview regarding medication availability for Residents #30 and #103 | |
| Director of Nursing | DON | Interviewed regarding medication errors, hospice services, enteral feeding, and pain management |
| Unit Manager E | Unit Manager | Interviewed regarding Resident #41's complaint and Resident #307's pain management |
| Dietary Manager H | Dietary Manager | Interviewed regarding nutrition assessments and dietary orders for Residents #307 and #308 |
| Registered Dietitian | RD I | Interviewed regarding dietary assessments for Residents #307 and #308 |
| CNA J | Certified Nursing Assistant | Witnessed sexual abuse incident involving Residents #309 and #59 |
| Maintenance Director M | Maintenance Director | Interviewed regarding environmental safety issues including open furnace door and kitchen drains |
| Human Resources Director | HR L | Interviewed regarding CNA annual competency training records |
| Social Services Manager | SS Manager G | Interviewed regarding Resident #307's hospice services |
| Administrator | Administrator | Interviewed regarding medication errors and environmental safety issues |
Inspection Report
Routine
Deficiencies: 16
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, advance directives, notification of changes, transfer/discharge procedures, MDS accuracy, care planning, pressure ulcer care, catheter care, pain management, dialysis care, pharmaceutical services, medication labeling and storage, infection prevention and control, and pest control.
Findings
The facility was found deficient in multiple areas including failure to provide privacy during dental care, incomplete advance directive assessments, lack of notification to responsible parties, inadequate transfer documentation, inaccurate MDS assessments, incomplete care plans, delayed physician wound documentation, inappropriate narcotic medication practices, incomplete dialysis communication forms, failure to follow infection control precautions, and ineffective pest control program.
Deficiencies (16)
Failed to provide privacy during dental care and assist residents with laundry, resulting in embarrassment and frustration.
Failed to ensure process for obtaining Resident Code Status was assessed, documented and accessible prior to physician's order for 6 residents.
Failed to inform responsible party of medication changes, pneumonia onset, and dental services for one resident, resulting in lack of communication for coordinated care.
Failed to ensure documentation of discharge summary, physician's order for discharge, and communication of essential health information upon transfer of one resident to hospital.
Failed to provide written notice of transfer to State Ombudsman and Resident Representative for one resident transferred to hospital.
Failed to ensure accuracy of Minimum Data Set assessment for one resident, resulting in inaccurate MDS with potential for unmet care needs.
Failed to review and revise care plans with resident changes to ensure necessary interventions for 5 residents, resulting in potential unmet care needs.
Failed to ensure assessment and wound care was consistently provided for pressure ulcers for three residents, resulting in residents not receiving necessary care to prevent or treat pressure ulcers.
Failed to ensure appropriate collection of urine sample for one resident and ensure urinary catheter securement device for another, resulting in potential misdiagnosis, delayed treatment, and irritation.
Failed to ensure residents received pain medication as ordered prior to wound care for one resident, resulting in potential increased pain and decreased quality of life.
Failed to ensure dialysis communication forms were complete and included pre- and post-dialysis assessment, assess dialysis access sites, and accommodate medication regimen for one resident, resulting in potential decline in condition.
Failed to obtain timely physician wound documentation for two residents, resulting in potential lack of care to promote prevention and treatment of pressure ulcers.
Failed to ensure appropriate narcotic medication practices including shift-to-shift narcotics count signatures, narcotics log signatures, and discrepancies in narcotics orders/packaging for four residents, resulting in potential inappropriate access and medication errors.
Failed to label medications appropriately, discard expired medications and supplies, and secure treatment cart with prescriptions for skin and wounds, resulting in use of expired equipment and decreased medication efficacy.
Failed to provide Covid testing for resident with signs and symptoms of infection, failed to ensure PPE was worn per standards for two residents, failed to analyze surveillance and implement corrective measures, and failed to track and report employee illness, resulting in potential for infectious illness and death.
Failed to maintain effective pest control program, resulting in presence of fruit flies and gnats in resident rooms, dining area, and hallways, potentially affecting all residents.
Report Facts
Residents reviewed for Advance Directives and Code Status: 8
Residents reviewed for notification of changes/services and care planning: 19
Residents reviewed for transfer/discharge: 3
Residents reviewed for MDS assessments: 23
Residents reviewed for care planning: 23
Residents reviewed for pressure ulcers and wounds: 4
Residents reviewed for catheter and urinary tract infections: 6
Residents reviewed for pain: 1
Residents reviewed for Dialysis care: 1
Residents reviewed for narcotics administration: 18
Residents reviewed for medication carts, medication rooms, and treatment carts: 2
Residents reviewed for infection prevention and control: 3
Residents reviewed for pest control complaints: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Q | Nurse | Named in narcotics administration and pain medication findings |
| Nurse E | Nurse | Named in wound care and infection control findings |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including privacy, notification, transfers, MDS, care plans, infection control, narcotics, and pest control |
| Nurse N | Unit Manager | Mentioned in dental privacy observation |
| Certified Nursing Assistant P | Certified Nursing Assistant | Observed assisting with wound care and nail care |
| Certified Nursing Assistant R | Certified Nursing Assistant | Interviewed about PPE use |
| Nurse L | Nurse | Interviewed about PPE use |
| Corporate Nurse T | Corporate Nurse | Interviewed regarding infection prevention and control |
| Nurse M | Nurse | Interviewed regarding medication room observations |
| Nurse J | Nurse | Observed with medication cart |
| Wound Care Nurse E | Wound Care Nurse | Interviewed and observed providing wound care |
| Wound Care Physician O | Physician | Interviewed regarding wound care documentation |
Inspection Report
Renewal
Census: 4
Capacity: 20
Deficiencies: 3
Date: Jun 6, 2023
Visit Reason
The inspection was conducted as a renewal licensing study for the Leighton House Inn facility to assess compliance with applicable rules and regulations.
Findings
The facility was found to be non-compliant with several rules including tuberculosis testing for staff, verification of employee education records, and proper storage of resident medications. Over-the-counter medications were found unsecured in residents' rooms.
Deficiencies (3)
One staff member's tuberculosis test was expired and a new staff member lacked written evidence of tuberculosis testing.
The facility did not obtain written verification of education for a staff member.
Over-the-counter medications were found unsecured in residents' rooms, not kept in locked cabinets or drawers as required.
Report Facts
Number of staff interviewed and/or observed: 3
Number of residents interviewed and/or observed: 4
Facility capacity: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Molly V. | Named in tuberculosis testing deficiency | |
| Anijah C. | Named in tuberculosis testing and education verification deficiencies | |
| Melissa Sevegney | Administrator | Licensee/Licensee Designee and Administrator of the facility |
| Susan Hutchinson | Licensing Consultant | Author of the inspection report |
Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 2
Date: Feb 24, 2023
Visit Reason
The investigation was initiated due to complaints alleging improper care of Resident E and failure of staff to respond to Resident D upon discharge from the hospital.
Complaint Details
Complaint alleged Resident E was not being cared for properly with staff not checking on her for up to four hours; this was not substantiated. Complaint also alleged that on 12/18/22, Resident D was discharged from hospital but staff did not answer door or phone, resulting in Resident D being taken back to hospital; this was substantiated.
Findings
The investigation found insufficient evidence to substantiate neglect of Resident E. However, a violation was substantiated regarding failure to answer the facility phone and door upon Resident D's hospital discharge, resulting in Resident D being taken back to the hospital. Additionally, a repeat violation was substantiated for failure to timely report an incident involving Resident D.
Deficiencies (2)
Failure to provide reasonable access to a telephone for private communications, resulting in inability to respond to hospital and ambulance staff.
Failure to timely report an incident involving serious hostility and hospitalization of a resident.
Report Facts
Capacity: 20
Complaint Receipt Date: Jan 12, 2023
Investigation Initiation Date: Jan 13, 2023
Report Due Date: Mar 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Sevegney | Administrator and Licensee Designee | Named in relation to findings and corrective action plan |
| Susan Hutchinson | Licensing Consultant | Author of the report |
| Kwadwo Owusu-Ansah | General Manager | Interviewed regarding complaint about phone and door access |
| Audraya Forrest | Staff | Completed Incident/Accident Report regarding Resident D |
Inspection Report
Original Licensing
Capacity: 20
Deficiencies: 0
Date: Jan 10, 2023
Visit Reason
The purpose of this addendum is to approve the change of controlling interest in the facility and update the file.
Findings
The submitted documentation was reviewed and it was determined that Symphony of Linden Health Care Center, LLC is now the owner/operator of the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Hutchinson | Licensing Consultant | Author of the addendum report and reviewer of the ownership change documentation. |
| Kimberly Gee | Administrator/Licensee Designee | New licensee designee who submitted documentation for change in controlling interest. |
Inspection Report
Original Licensing
Capacity: 20
Deficiencies: 0
Date: Jun 23, 2008
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for the Leighton House Inn facility.
Findings
The facility was found to be in substantial compliance with licensing requirements, including full approval from the Genesee County Health Department and Bureau of Fire Safety. The physical facility and program description meet standards for an adult foster care large group home with a capacity of 20 residents.
Report Facts
Capacity: 20
Inspection Date: Jun 23, 2008
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Clark | Licensing Consultant | Author of the licensing study report and recommendation |
| Gregory Rice | Area Manager | Approved the licensing study report |
| Deborah Durham | Licensee Designee | Licensee designee named in the report |
| Stephanie Hildebrant | Administrator | Administrator named in the report |
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