Inspection Reports for The Woodlands of DeWitt

MI, 48820

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Deficiencies per Year

4 3 2 1 0
2020
2022
2023
2024
Unclassified

Census Over Time

20 30 40 50 60 70 Dec '22 May '23
Census Capacity
Inspection Report Complaint Investigation Capacity: 45 Deficiencies: 3 Sep 25, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident B did not receive care according to the service plan, ran out of prescribed eye drops, had dirty sheets, and did not receive water as required.
Findings
The investigation found violations related to Resident B not receiving care according to the service plan, including failure to document refusals of showers and missed medication doses. The facility did not ensure prescribed eye drops were administered as ordered and failed to contact the physician regarding missed doses. No violations were found regarding dirty sheets or water provision.
Complaint Details
The complaint alleged Resident B did not receive personal care as per service plan, ran out of Lumigen eye drops, had dirty sheets, and did not receive water as preferred. Some allegations were substantiated (care not provided per plan, medication issues), while others (dirty sheets, water provision) were not substantiated.
Deficiencies (3)
Description
Resident B care not provided in accordance with service plan; failure to document refusals of shower assistance.
Resident B ran out of prescribed Lumigen eye drops and medication was not administered as prescribed.
Facility failed to contact the physician regarding missed doses of Bimatoprost medication.
Report Facts
Capacity: 45 Missed medication doses: 9 Medication delivery delay: 4
Employees Mentioned
NameTitleContext
Evonne WhiteAdministratorReported on care provision and medication issues related to Resident B
Kimberly HorstLicensing StaffConducted investigation and authored report
Mandy MarinRegistered Nurse, University of Michigan-Sparrow Home HospiceInterviewed regarding Resident B's care and medication
Becky RiegelPharmacy Department, Advanced Specialty RxInterviewed regarding medication refill and delivery
Inspection Report Complaint Investigation Capacity: 45 Deficiencies: 1 Jul 8, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident B was not involved in the development of their service plan.
Findings
The investigation found that Resident B did not participate in the development of their service plan as there was no documentation or signature evidencing participation, establishing a violation of the admission and retention of residents rule.
Complaint Details
The complaint alleged that Resident B was not involved in the development of the service plan. The investigation substantiated this allegation and established a violation.
Deficiencies (1)
Description
Resident B was not involved in the development of the service plan.
Report Facts
Capacity: 45 Complaint Receipt Date: Jul 2, 2024 Investigation Initiation Date: Jul 2, 2024 Report Due Date: Sep 1, 2024
Employees Mentioned
NameTitleContext
Evonne WhiteAdministratorInterviewed regarding Resident B's service plan development
Andrea MooreLong-Term-Care State Licensing Section ManagerConducted complaint interview and approved report
Kimberly HorstLicensing StaffConducted investigation and authored report
Inspection Report Complaint Investigation Capacity: 45 Deficiencies: 1 Jan 5, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility did not allow Relative B1 to visit Resident B on 01/01/2024 due to no management being on site.
Findings
The investigation found that Relative B1 was denied visitation on 01/01/2024 because there was no management present, and the caregivers refused entry. A physician's order limited Relative B1's visitation to weekdays from 9:00 to 17:00 in a public area, excluding mealtimes. The denial of visitation was consistent with the physician's order and facility policy. The complaint was substantiated as a violation.
Complaint Details
Complaint received on 01/04/2024 alleged the facility denied visitation to Relative B1 on 01/01/2024 due to no management on site. Investigation confirmed denial of visitation consistent with physician order and facility policy. Violation established.
Deficiencies (1)
Description
Facility did not allow Relative B1 to visit Resident B as per physician's visitation limitations and facility policy.
Report Facts
Capacity: 45 Complaint Receipt Date: Jan 4, 2024 Investigation Initiation Date: Jan 5, 2024
Employees Mentioned
NameTitleContext
Evonne WhiteAdministratorInterviewed regarding visitation denial and facility policies
Kimberly HorstLicensing StaffConducted investigation and authored report
Inspection Report Complaint Investigation Capacity: 45 Deficiencies: 2 Aug 16, 2023
Visit Reason
The investigation was initiated due to a complaint alleging that Resident A was issued an improper discharge and that the discharge letter did not provide correct appeal information.
Findings
The investigation found that Resident A was improperly discharged due to the guardian's statements towards staff, which did not meet licensing criteria. Additionally, the discharge letter failed to provide correct information on how to file a complaint with the Licensing Department. Both violations were established.
Complaint Details
The complaint alleged that Resident A was issued an improper discharge and that the discharge letter did not provide correct appeal information. Both violations were substantiated.
Deficiencies (2)
Description
Resident A was issued an improper discharge.
Resident A discharge letter did not provide correct appeal information.
Report Facts
Capacity: 45 Complaint Receipt Date: Aug 16, 2023
Employees Mentioned
NameTitleContext
Kimberly HorstLicensing StaffLicensing staff who conducted the investigation
Andrea L. MooreManager, Long-Term-Care State Licensing SectionManager who approved the report
Inspection Report Complaint Investigation Capacity: 45 Deficiencies: 1 Jul 18, 2023
Visit Reason
The investigation was initiated due to an anonymous complaint alleging that Resident A was given morphine without a prescription at The Woodlands Of DeWitt facility.
Findings
The investigation found that Resident A had a physician-ordered prescription for morphine; however, medication administration records showed varying doses and administration outside of physician orders, including a documented instance where morphine was given based on the resident's wife's request despite no pain. The facility was found to be in violation due to inconsistent documentation and administration practices.
Complaint Details
The complaint alleged that Resident A was given morphine without a prescription. The allegation was substantiated with violation established.
Deficiencies (1)
Description
Resident A was administered morphine outside of physician orders and inconsistent documentation of medication administration records was found.
Report Facts
Capacity: 45 Medication administration instances: 22 Medication administration instances: 16
Employees Mentioned
NameTitleContext
Evonne WhiteAdministratorInterviewed regarding Resident A's care and medication administration
Julie VivianoLicensing StaffAuthor of the Special Investigation Report
Inspection Report Complaint Investigation Capacity: 45 Deficiencies: 3 Jun 27, 2023
Visit Reason
The investigation was initiated due to a complaint alleging that Resident C was not provided medical attention, residents were not treated respectfully, Staff Person 5 was not trained in medication administration, and medications were not administered properly.
Findings
The investigation established violations related to Resident C not receiving timely medical attention for a UTI, Staff Person 5 not being properly evaluated for medication administration competencies, and staff failing to initial medication administration on multiple occasions. The allegation that residents were not treated respectfully was not substantiated.
Complaint Details
The complaint alleged that Resident C was not provided medical attention for a urinary tract infection for one week, residents were not treated respectfully, Staff Person 5 was not trained in medication administration, and medications were not administered properly. The investigation substantiated the allegations regarding Resident C's medical attention, Staff Person 5's training, and medication administration, but did not substantiate disrespectful treatment of residents.
Deficiencies (3)
Description
Resident C was not provided timely medical attention for a urinary tract infection.
Staff Person 5 was not properly evaluated for competencies in medication administration.
Staff failed to initial medication administration on multiple occasions, making it difficult to verify if medications were given.
Report Facts
Capacity: 45 Medication administration omissions: 13
Employees Mentioned
NameTitleContext
Evonne WhiteAdministratorInterviewed regarding Resident C's medical attention and facility practices
Kimberly HorstLicensing StaffAuthor of the Special Investigation Report
Inspection Report Complaint Investigation Census: 32 Capacity: 45 Deficiencies: 1 May 17, 2023
Visit Reason
The inspection was conducted in response to an anonymous complaint alleging the facility has insufficient staff and residents wait a long time for staff assistance.
Findings
The investigation found that the facility did not have adequate staffing to meet the care needs of residents, particularly in the memory care unit where staffing ratios left some hallways unattended. The facility was found to be in violation of staffing requirements.
Complaint Details
The complaint alleged insufficient staffing causing residents to wait a long time for assistance. The complaint was substantiated with a violation established.
Deficiencies (1)
Description
Facility has insufficient staff to meet resident needs consistent with their service plans.
Report Facts
Capacity: 45 Census: 32 Staffing counts: 5 Staffing counts: 4 Dates with low staffing: 4
Employees Mentioned
NameTitleContext
Evonne WhiteAdministratorInterviewed regarding staffing and facility operations.
Kimberly HorstLicensing StaffAuthor of the Special Investigation Report.
Andrea L. MooreManager, Long-Term-Care State Licensing SectionApproved the report.
Inspection Report Complaint Investigation Capacity: 45 Deficiencies: 2 May 17, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility did not allow Resident B to speak with Relative B1.
Findings
The investigation found that the facility limited visitation between Resident B and Relative B1 without a physician's documented medical contraindication. Additionally, the admission agreement was signed by a relative rather than Resident B, rendering it invalid.
Complaint Details
Complaint alleged the facility did not allow Relative B1 to visit Resident B. The complaint was substantiated as a violation was established.
Deficiencies (2)
Description
Facility limited Resident B's right to associate with Relative B1 without documented medical contraindication.
Admission agreement was not validly signed by Resident B but by a relative.
Report Facts
Facility capacity: 45
Employees Mentioned
NameTitleContext
Evonne WhiteAdministratorInterviewed regarding visitation and resident care
Kimberly HorstLicensing StaffAuthor of the Special Investigation Report
Andrea L. MooreManager, Long-Term-Care State Licensing SectionApproved the report
Inspection Report Complaint Investigation Census: 60 Capacity: 45 Deficiencies: 1 Dec 15, 2022
Visit Reason
The investigation was initiated due to a complaint alleging insufficient staffing to meet resident care needs, lack of staff training for medication administration, residents not being bathed, and a resident's bed being too small.
Findings
The investigation found no violations regarding staffing levels, medication administration training, or bathing practices. However, a violation was established related to Resident C's service plan lacking instructions for the hospital bed and bed rails, which posed a protection concern.
Complaint Details
Complaint alleged insufficient staff to meet resident care needs, staff not trained to administer medications, residents not being bathed, and Resident C's bed being too small. Violations were not established for staffing, training, or bathing. Violation established for inadequate service plan regarding Resident C's bed.
Deficiencies (1)
Description
Resident C's service plan did not address the hospital bed use, physician order, or instructions for staff to check bed rails for tightness or gaps.
Report Facts
Capacity: 45 Census: 60 Complaint Receipt Date: Dec 6, 2022 Investigation Initiation Date: Dec 9, 2022 Report Due Date: Feb 5, 2023
Employees Mentioned
NameTitleContext
Cheri CordellAdministratorProvided staff schedule, interviewed regarding staffing and training
Lauren WohlfertLicensing StaffConducted investigation and authored report
Clarence RivetteAuthorized RepresentativeRecipient of report and corrective action plan request
Inspection Report Original Licensing Capacity: 45 Deficiencies: 0 Apr 29, 2020
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for The Woodlands Of DeWitt facility.
Findings
The facility was found to be in substantial compliance with home for the aged public health code and administrative rules. The facility has approved fire safety certification, occupancy approval, and an approved emergency generator. The program provides services to individuals aged 55 and older, including those diagnosed with Alzheimer's disease or related conditions.
Report Facts
Licensed bed capacity: 45
Employees Mentioned
NameTitleContext
Kathleen LeslieAdministratorNamed as the facility administrator.
Clarence RivetteAuthorized RepresentativeNamed as the authorized representative for the licensee.
Lauren WohlfertLicensing StaffAuthor of the licensing study report.
Russell B. MisiakArea ManagerApproved the licensing study report.
Barbara ZabitzLicensing Staff PersonReviewed the facility’s memory care program statement and compliance.

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