Deficiencies per Year
4
3
2
1
0
Unclassified
Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 1
Feb 21, 2025
Visit Reason
The investigation was initiated due to a complaint alleging that staff did not administer Resident A’s Norco medication as prescribed for pain.
Findings
The investigation found that Resident A did not receive her prescribed Norco medication from 2/4/2025 to 2/12/2025 because the medication was not available at the facility. Staff failed to follow medication refill procedures, resulting in Resident A going without medication for nine days and being sent to the hospital for pain management.
Complaint Details
Complaint alleged that staff did not administer Resident A’s Norco medication as prescribed. APS Specialist Lauren Crock investigated and found no substantial evidence of neglect or abuse, attributing the issue to the facility running out of medication. The investigation confirmed the medication was not administered from 2/4/2025 to 2/12/2025 due to lack of refill and staff procedural failures.
Deficiencies (1)
| Description |
|---|
| Staff did not administer Resident A’s Norco medication as prescribed for pain due to failure to follow medication refill procedures. |
Report Facts
Medication non-administration duration: 9
Facility capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexis Craft | Direct Care Staff Member | Interviewed regarding medication administration and refill procedures; issued disciplinary notice. |
| Lomachia Cox | Direct Care Staff Member | Interviewed regarding medication administration; received disciplinary notice for medication error. |
| Hailey Nichols | Direct Care Staff Member | Interviewed regarding medication administration and refill procedures. |
| Laurel Space | Administrator | Participated in exit conference. |
| Catherine Reese | Licensee Designee | Participated in exit conference. |
| Lauren Crock | Adult Protective Service Specialist | Investigated complaint and provided information on substantiation. |
Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 1
Jan 9, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that a resident was given all of their PRN medications at once and concerns about a direct care staff member's ability to administer medications properly.
Findings
The investigation found no evidence that the resident was given all PRN medications at once and confirmed that the direct care staff member was properly trained to administer medications. However, a violation was established for failure to document the time and date of a morphine dose administered to the resident.
Complaint Details
The complaint alleged that Resident A was given all his PRN medications at once by a third shift staff member and that direct care staff Cheryl [Unknown] did not know how to give medications. The investigation did not substantiate these allegations.
Deficiencies (1)
| Description |
|---|
| Direct care staff failed to document the time and date when administering a dose of Morphine to Resident A despite initialing the medication was administered. |
Report Facts
Capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cheryl Harrison | Direct Care Staff | Named in complaint alleging lack of medication administration knowledge; found to be properly trained |
| Laurel Space | Administrator | Interviewed during investigation and participated in exit conference |
| Rachel Ignasiban | Direct Care Staff | Administered morphine doses to Resident A; failed to document time and date for one dose |
| Sarah Dunning | Direct Care Staff | Interviewed during investigation |
| Cathy Cushman | Licensing Consultant | Author of the report and recommendation |
| Dawn N. Timm | Area Manager | Approved the report |
Inspection Report
Renewal
Census: 7
Capacity: 20
Deficiencies: 4
Dec 7, 2023
Visit Reason
The inspection was conducted as a renewal licensing study to verify compliance with licensing statutes and administrative rules for Vibrant Life Senior Living Kalamazoo Lodge 1.
Findings
The facility was found to be in non-compliance with several rules related to administrator training, tuberculosis testing verification, health status review, and emergency preparedness fire drills. An acceptable corrective action plan was submitted and approved, and renewal of the license is recommended.
Deficiencies (4)
| Description |
|---|
| Administrator did not provide evidence of completing 16 hours of required training. |
| Administrator did not provide written verification of tuberculosis testing every 3 years. |
| No health status review provided to the department for the administrator. |
| No recorded practices of fire drills provided to the department for review. |
Report Facts
Capacity: 20
Residents observed/interviewed: 7
Staff interviewed/observed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Space | Administrator | Named in findings related to training, tuberculosis testing, and health status review deficiencies |
Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 0
Nov 15, 2023
Visit Reason
The investigation was initiated due to a complaint alleging that the facility office smelled of marijuana and that a staff member was selling marijuana-based products at the facility.
Findings
The investigation found no evidence of marijuana smell in the facility or staff selling marijuana products on the premises. Multiple staff members and the licensee designee denied knowledge of such activities, and no staff were observed impaired or under the influence. The allegation was not substantiated.
Complaint Details
The complaint alleged the facility office smelled of marijuana and a staff member was selling marijuana-based products at the facility. The allegation was investigated through interviews with current and former staff and onsite inspection. No violation was established.
Report Facts
Capacity: 20
Complaint Receipt Date: Sep 25, 2023
Investigation Initiation Date: Sep 25, 2023
Report Due Date: Nov 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cory Shell | Facility Chef | Named in allegation and investigation regarding selling marijuana products |
| Catherine Reese | Licensee Designee | Interviewed and involved in exit conference |
| Ondrea Johnson | Licensing Consultant | Conducted investigation and authored report |
Inspection Report
Complaint Investigation
Capacity: 20
Deficiencies: 0
Oct 25, 2022
Visit Reason
The investigation was initiated due to a complaint alleging that Resident A went for hours without receiving prescribed morphine medication.
Findings
The investigation found no evidence that Resident A went without morphine as prescribed. The medication was prescribed as needed, and staff confirmed Resident A received medication appropriately. The complaint was not substantiated.
Complaint Details
Complaint alleged Resident A went hours without morphine medication on 08/30/2022. Investigation included interviews with multiple staff and review of medication administration records. The complaint was not substantiated as Resident A's morphine was prescribed as needed and was administered accordingly.
Report Facts
Capacity: 20
Complaint Receipt Date: Sep 21, 2022
Investigation Initiation Date: Sep 21, 2022
Inspection Date: Oct 25, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurel Space | Administrator | Interviewed regarding complaint and medication administration |
| Lisa Matthews | Hospice Nurse | Interviewed and reviewed medication administration records |
| Laticia Scott | Nursing Director | Interviewed regarding medication administration and complaint |
| Ashley Ebling | Direct Care Staff Member | Interviewed; expressed belief of possible cover-up but provided no evidence |
| Alexis Craft | Staff Member | Participated in on-site inspection and confirmed medication administration |
Inspection Report
Original Licensing
Capacity: 20
Deficiencies: 0
Dec 15, 2020
Visit Reason
The visit was conducted to process a request by the licensee designee to change the facility's name from New Friends Dementia Community 1 to Vibrant Life Senior Living Kalamazoo 1.
Findings
The licensing consultant verified that the requested name change was not due to a change of licensee or controlling interest and recommended approval of the name change.
Report Facts
Facility capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Catherine Reese | Licensee Designee | Requested the facility name change |
| Michele Streeter | Licensing Consultant | Conducted the licensing study and verified findings |
| Dawn Timm | Area Manager | Approved the facility name change |
Inspection Report
Original Licensing
Capacity: 20
Deficiencies: 0
May 25, 2011
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for New Friends Dementia Community 1.
Findings
The facility was found to be in substantial compliance with licensing requirements, including physical environment, staffing, and program policies. A temporary six-month license with a maximum capacity of 20 residents was recommended and issued.
Report Facts
Capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dean Solden | Administrator/Licensee Designee | Named as licensee designee and administrator with experience in adult foster care and assisted living facilities. |
| Jill Hess | Administrator | Appointed administrator with extensive experience in dementia and Alzheimer’s care. |
| Susan Gamber | Licensing Consultant | Author of the licensing study report and signatory recommending issuance of temporary license. |
| Gregory V. Corrigan | Area Manager | Approved the licensing recommendation. |
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