Inspection Reports for
Symphony Linden
202 S Bridge St, Linden, MI 48451, United States, MI, 48451
Back to Facility Profile3 Reports
Inspection Report — May 29, 2025
Renewal
Date: May 29, 2025
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The home was found in non-compliance with 3 rules; a written corrective action plan was required before the license is renewed.
Deficiencies (3)
R 400.15318 Emergency preparedness; evacuation plan; emergency transportation: the facility was unable to produce documentation that fire drills were conducted during April 2023 – December 2023, January 2024 – March 2024, January 2025, and May 2025.
R 400.15403 Maintenance of premises: there was a large hole in the laundry room wall near the dryer vent; all walls shall be kept in good repair.
R 400.15407 Bathrooms: several resident bathrooms were not equipped with operational ventilation fans; all bathrooms without windows shall have forced ventilation to the outside.
Report Facts
Corrective action plan due: 15
Inspection Report — Jan 10, 2023
Date: Jan 10, 2023
Visit Reason
Change of controlling interest in the facility; approval of new ownership.
Findings
Symphony of Linden Health Care Center, LLC is now the owner/operator of this facility.
Inspection Report — Oct 29, 2007
Original Licensing
Date: Oct 29, 2007
Visit Reason
Original license application for an adult foster care large group home.
Findings
The applicant was found to be in substantial compliance with the licensing act and applicable administrative rules.
7 CMS Surveys
Inspection Report — Sep 9, 2025
Complaint Investigation
Date: Sep 9, 2025
Visit Reason
Investigation of a complaint received on 2025-09-03 about resident rights, environment cleanliness, care planning, infection control, and safety.
Findings
Multiple deficiencies were found including failure to ensure residents were treated with dignity and respect, unclean and unsafe environment, incomplete and outdated care plans for residents, inadequate infection prevention and control program, and failure to ensure proper backflow prevention in the water system.
Deficiencies (5)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to address missing personal items, visitation hour restrictions, and after-hours phone and door access issues.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: multiple resident rooms and bathrooms were unclean with foul odors, rust stains, soiled toilets and sinks, overflowing trash, and uncovered toothbrushes.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: care plans for residents #21, #22, #60, and #67 lacked resident-specific interventions and were not updated after incidents such as falls, infections, and skin breakdown.
F 0880 Provide and implement an infection prevention and control program: the facility failed to maintain continuous infection surveillance, lacked environmental rounds, had incomplete water management documentation, and staff failed to use appropriate personal protective equipment.
F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: the facility failed to ensure appropriate backflow prevention was installed on cross connections, increasing the risk of water contamination.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in the infection control finding for failing to apply proper personal protective equipment during medication administration. |
Inspection Report — Sep 9, 2025
Renewal
Date: Sep 9, 2025
Visit Reason
Renewal inspection of the nursing home license.
Findings
Multiple deficiencies were cited including failure to ensure residents' rights, inadequate care planning, infection control issues, medication management problems, environmental cleanliness, and safety hazards.
Deficiencies (15)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to timely replace missing items for Resident #22 and failed to ensure timely reentry after hours for residents, resulting in resident dissatisfaction and rights violations.
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: Resident #21's code status was inaccurately documented and accessible, with the Care Plan contradicting the DNR order for over a month.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: multiple resident rooms and bathrooms on the 100, 200, and 300 halls were unclean with foul odors, soiled toilets and sinks, overflowing wastebaskets, and uncovered toothbrushes.
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: PASARR assessments were not completed yearly or posted for residents #7 and #10, contrary to facility policy and state requirements.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: Residents #21, #22, #60, and #67 lacked resident-specific interventions in their care plans, including fall prevention, infection control, and pressure ulcer management.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #6 had untreated wounds on the nose and lip with no documented treatment for the lip wound; Residents #60 and #65 were receiving hospice care without proper orders or documentation.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Resident #7 fell and sustained a head injury; care plan and supervision were inadequate to prevent the fall and address toileting needs.
F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: Residents #13 and #60 were prescribed psychotropic medications without proper consents and behavior monitoring documentation.
F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: Expired supplements and medications were found in medication rooms and carts; unlabeled and loose medications were present in medication carts.
F 0814 Dispose of garbage and refuse properly: Dumpster area was soiled with dark waste, open lids, and trash including dirty gloves and food wrappers, increasing risk of pests and contamination.
F 0880 Provide and implement an infection prevention and control program: Facility lacked an active water management plan to reduce legionella risk; incomplete infection surveillance data and reporting; inadequate environmental cleaning; improper PPE use by staff; and residents with multi-drug resistant organisms had unclean rooms and bathrooms.
F 0881 Implement a program that monitors antibiotic use: Facility failed to identify and review resistance patterns of organisms in antibiotic stewardship meetings due to incomplete infection surveillance data, risking ineffective antibiotic use.
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: Residents were not consistently assessed or educated about vaccinations; vaccination documentation was incomplete or missing; staff lacked training on vaccination education.
F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status: Residents were not consistently assessed or educated about COVID-19 vaccination; documentation was incomplete or missing; staff lacked training on vaccination education.
F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: Inappropriate backflow prevention devices were installed in the facility's plumbing system, increasing risk of water contamination.
Inspection Report — Jan 23, 2025
Complaint Investigation
Date: Jan 23, 2025
Visit Reason
Investigation of a complaint received about the facility's cleanliness and linen supply.
Findings
The facility failed to provide a clean, comfortable, and homelike environment by not ensuring residents' rooms and bathrooms were clean and by lacking sufficient clean linens, resulting in resident dissatisfaction and complaints.
Deficiencies (2)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility failed to ensure Resident #1's bathroom was clean with stained toilet bowl and floor, and lacked clean towels and washcloths for resident use.
F 0584 The facility failed to maintain Resident #5's bathroom with large dark orange stains in the sink and toilet, soiled floor, and an unlabeled bed pan on a commode chair.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide E | Nurse Aide | Observed sorting Resident #1's clothes and towels during the investigation. |
Inspection Report — Dec 3, 2024
Complaint Investigation
Date: Dec 3, 2024
Visit Reason
Investigation of a complaint received on 2024-12-03 about failure to maintain bladder scanner equipment and related resident care.
Complaint Details
Failure to maintain bladder scanner equipment: violation established.
Findings
The facility failed to ensure that the bladder scanner was in good repair, resulting in delayed urinary care and complications for one resident with indwelling catheters.
Deficiencies (1)
F 0908 Keep all essential equipment working safely: the bladder scanner was broken and unavailable, causing delayed urinary retention assessment and complications for Resident #500.
Inspection Report — Aug 22, 2024
Renewal
Date: Aug 22, 2024
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The facility was found to have multiple deficiencies including failure to ensure timely medication administration, inadequate pain management, failure to maintain safe and sanitary environment, failure to maintain annual competencies for nursing staff, failure to ensure proper nutrition and feeding tube care, failure to protect residents from abuse, and failure to ensure proper hospice communication.
Deficiencies (12)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: Residents experienced delayed call light responses, call lights not within reach, staff talking on personal phones during care, inadequate snacks, and poor housekeeping and laundry services.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: Resident #59 was sexually abused by Resident #309 who was found with his hand down Resident #59's pants. Facility failed to implement adequate interventions and care plans to prevent repeated inappropriate behavior.
F 0610 Respond appropriately to all alleged violations: Facility failed to retain complete documentation regarding an injury after a fall for Resident #56, including incomplete incident report and lack of follow-up documentation.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: Resident #39 developed four facility-acquired pressure ulcers due to failure to implement and carry out proper interventions including positioning and skin care.
F 0692 Provide enough food/fluids to maintain a resident's health: Residents #307 and #308 lacked timely nutritional assessments and monitoring. Resident #307 had delayed diet order changes despite chewing difficulties and Resident #308 had inconsistent food intake documentation and delayed dietary assessment.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: Resident #39's enteral feeding was infused at a lower rate than ordered without documentation of total intake, risking inadequate nutrition.
F 0697 Provide safe, appropriate pain management for a resident who requires such services: Resident #307 experienced unrelieved pain and delayed pain medication orders including morphine and cough syrup, resulting in verbalized discomfort and frustration.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: Facility failed to maintain annual competency training of 12 hours for three CNAs, with incomplete or missing documentation of in-service training hours and evaluations.
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: Facility failed to ensure timely availability and administration of medications for Residents #30 and #103, including Lidocaine 4% patch and Lantus insulin injection, resulting in medication errors and potential adverse effects.
F 0760 Ensure that residents are free from significant medication errors: Resident #103 missed Lantus insulin injection and was given inadequate pain medication without proper pain assessment, resulting in potential for serious adverse effects and inadequate pain control.
F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services: Facility failed to ensure proper communication and documentation of hospice services for Resident #39, with absence of progress notes since 06/03/24 despite ongoing hospice care.
F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: Multiple kitchen drains had stagnated water, sewage odors, drain flies, and leaks. Maintenance failed to properly maintain or repair these issues. Additionally, an opened furnace closet door was found in a resident room, and hallways and dining areas were dirty and sticky, posing safety and sanitation risks.
Inspection Report — Aug 22, 2024
Renewal
Date: Aug 22, 2024
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
Multiple deficiencies were found including failure to ensure resident dignity and timely call light response, failure to protect residents from sexual abuse, incomplete incident investigations, inadequate care planning for nutrition and restorative therapy, pressure ulcer prevention failures, medication administration errors exceeding 5%, unsafe medication storage, and unsanitary conditions in the kitchen and resident areas.
Deficiencies (14)
F 0550 Resident dignity and timely response: residents experienced soiled briefs due to call lights not being answered timely, call lights not within reach, and staff talking on personal cell phones during care.
F 0600 Protect residents from abuse: Resident #59 was sexually abused by Resident #309 who entered her room and touched her inappropriately; facility failed to implement adequate interventions and care plans to prevent repeated incidents.
F 0610 Incident investigation incomplete: facility failed to retain complete documentation regarding injury after fall for Resident #56, missing interviews, statements, and follow-up assessments.
F 0655 Care planning: Resident #307 and Resident #308 did not have timely, individualized care plans addressing nutritional needs within 48 hours of admission.
F 0656 Care planning: Resident #23 lacked a comprehensive care plan for use and maintenance of CPAP machine, including cleaning and mask/tubing replacement.
F 0686 Pressure ulcer care: Resident #39 developed four facility-acquired pressure ulcers due to failure to implement and carry out prevention interventions including positioning and skin care.
F 0692 Nutrition monitoring: Residents #307 and #308 lacked timely nutritional assessments and consistent monitoring of food intake, resulting in risk for malnutrition.
F 0695 Respiratory care: Residents #9, #23, and #34 had improperly cleaned, unlabeled, or improperly stored respiratory equipment including CPAP and nebulizer, risking infection and health deterioration.
F 0732 Nurse staffing: Facility failed to maintain complete and accurate daily clinical staff postings for multiple months, including missing data and incomplete forms, impairing transparency for residents and visitors.
F 0755 Pharmaceutical services: Resident #30 did not receive Lidocaine 4% patch due to unavailability; Resident #103 did not receive Lantus insulin injection due to delayed pharmacy delivery, resulting in medication errors exceeding 5%.
F 0760 Medication management: Resident #103 experienced significant medication errors including omission of Lantus insulin and inadequate pain management, with delayed medication availability and failure to assess pain properly.
F 0761 Medication storage: Medication cart in 300 Hall left unlocked and unattended with resident information exposed; treatment cart unlocked and unsecured; topical medications stored improperly with oral medications; multiple unlabeled or undated medications and supplies.
F 0849 Hospice services: Facility failed to ensure timely receipt and documentation of hospice progress notes for Resident #39, with last note dated 06/03/24 despite ongoing hospice care.
F 0921 Environmental safety: Kitchen drains had stagnated water, sewage odors, drain flies, and leaks; dining room floor sticky; resident rooms with urine odor and stained carpets; hallways with debris and insufficient cleaning.
Report Facts
Medication error rate: 6.25
Pressure ulcer count: 4
Medication administration delay: 4
Medication administration delay: 5
Medication administration delay: 6
Inspection Report — Sep 28, 2023
Renewal
Date: Sep 28, 2023
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The facility was found to have multiple deficiencies including failure to provide privacy during dental care, failure to ensure proper assessment and documentation of resident code status, failure to notify responsible parties of changes in condition, failure to ensure proper transfer documentation and notification, inaccurate MDS assessments, incomplete care plans, inadequate wound care and pain management, inconsistent narcotic medication practices, improper medication labeling and storage, and failure to maintain an effective infection prevention and control program.
Deficiencies (17)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: The facility failed to provide privacy during dental care for Resident #8 and assist Resident #33 with putting laundry away, resulting in embarrassment and frustration.
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: The facility failed to ensure a process for obtaining, documenting, and assessing Resident Code Status for 6 residents, resulting in potential miscommunication and lack of informed knowledge.
F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: The facility failed to inform the responsible party of the start of a gradual dose reduction for Depakote, onset of pneumonia, and dental services for Resident #33, resulting in lack of communication and coordinated care.
F 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged: The facility failed to ensure documentation of discharge summary, physician's order for discharge, and communication of essential health information to the hospital for Resident #21, resulting in potential lack of communication for continuation of care.
F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: The facility failed to provide written notice of transfer to the State Ombudsman and Resident Representative for Resident #21, resulting in lack of advocacy and uninformed representatives.
F 0641 Ensure each resident receives an accurate assessment: The facility failed to ensure accuracy of the MDS assessment for Resident #26 by incorrectly documenting septicemia, resulting in potential unmet care needs.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: The facility failed to develop and implement a comprehensive care plan for Resident #112 to coordinate hospice services, resulting in lack of coordination of care.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: The facility failed to review and revise care plans with resident changes for Residents #2, #4, #44, #51, and #164, resulting in potential unmet care needs.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: The facility failed to ensure consistent assessment and wound care for pressure ulcers for Residents #18, #38, and #51, resulting in residents not receiving necessary care to prevent worsening wounds.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: The facility failed to ensure appropriate collection of urine samples for Resident #32 and failed to ensure an indwelling urinary catheter securement device for Resident #51, resulting in potential misdiagnosis, delayed treatment, and irritation.
F 0697 Provide safe, appropriate pain management for a resident who requires such services: The facility failed to ensure Resident #51 received pain medication as ordered prior to wound care, resulting in increased pain and decreased quality of life.
F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services: The facility failed to ensure dialysis communication forms were complete and consistent for Resident #25, resulting in potential decline in condition and inability for prompt response to care needs.
F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care: The facility failed to ensure timely physician assessments and documentation for Residents #18 and #51, resulting in potential lack of care to promote prevention and treatment of pressure ulcers.
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: The facility failed to ensure appropriate narcotic medication practices including shift-to-shift narcotic counts, proper signing out of narcotics, and consistency between medication orders and packaging for Residents #4, #14, #22, #25, and #112, resulting in potential inappropriate access and medication errors.
F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: The facility failed to label eye drops with open dates, failed to discard expired medications and supplies, and failed to secure a treatment cart with prescription medications, resulting in potential administration of ineffective medications and use of expired supplies.
F 0880 Provide and implement an infection prevention and control program: The facility failed to provide Covid testing for Resident #56 with symptoms, failed to ensure PPE use per standards for Residents #18 and #112, failed to analyze surveillance data and implement corrective measures, and failed to track and report employee illness, resulting in potential for infectious illness spread and adverse outcomes.
F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: The facility failed to maintain an effective pest control program to prevent fruit flies and drain flies in the building, resulting in resident and staff complaints and potential health hazards.
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