Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 94
Deficiencies: 1
Mar 12, 2024
Visit Reason
The inspection was conducted in response to an anonymous complaint alleging that food in the Memory Care Unit was not served at the proper temperature, a regular occurrence during breakfast.
Findings
The investigation found that food temperatures were inconsistently recorded and often missing for hot food items served to residents. The facility did not use warming trays or steam tables during food transfer to the memory care unit, and the logs did not distinguish between assisted living and memory care food temperatures. A violation was established due to lack of evidence that food was served at safe temperatures.
Complaint Details
The complaint was anonymous and alleged that food in the Memory Care Unit was not served at proper temperature, particularly during breakfast. The complaint was forwarded from the Oakland County Health Department. The violation was substantiated based on inspection findings.
Deficiencies (1)
| Description |
|---|
| Food is not served at the proper temperature. |
Report Facts
Capacity: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joe Whitney | Administrator | Interviewed regarding food preparation and temperature issues |
Inspection Report
Renewal
Deficiencies: 0
Feb 12, 2024
Visit Reason
An administrative review of licensing activity for the past year was conducted to assess compliance with public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.
Findings
The facility demonstrated substantial compliance with applicable regulations, leading to the renewal of the Home for the Aged license effective 03/11/2024.
Inspection Report
Renewal
Census: 43
Capacity: 94
Deficiencies: 9
Mar 7, 2023
Visit Reason
The inspection was conducted as a renewal licensing study to assess compliance with regulatory requirements for Waltonwood at Twelve Oaks II.
Findings
The facility was found to be in non-compliance with multiple rules including employee tuberculosis screening delays, medication administration errors, improper furniture charges, hazardous conditions due to ongoing renovations, unsafe storage of solid wastes and food items, inadequate heating, and poor general maintenance and storage.
Deficiencies (9)
| Description |
|---|
| Employee tuberculosis screening was not conducted within 10 days of hire for three employees. |
| Resident medications were missed or improperly documented, including multiple missed doses of Gabapentin, Hydrocodone, and Tolcylen. |
| Facility charged residents for furniture items that must be provided without charge according to administrative rules. |
| Construction debris, tools, and equipment were present in resident accessible areas without separation from residents, creating hazards. |
| Six garbage cans in the commercial kitchen were observed without lids. |
| Thermostat in memory care unit read 70°F, below the required minimum of 72°F. |
| Perishable food items were improperly stored, uncovered, unlabeled, or undated, risking food safety. |
| Poisonous cleaning agents were stored in food preparation and serving areas, risking contamination. |
| Building and accessible areas were not kept clean or in good repair, with debris and dust present throughout. |
Report Facts
Number of staff interviewed and/or observed: 21
Number of residents interviewed and/or observed: 43
Facility capacity: 94
Number of excluded employees followed up: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steven Tyshka | Authorized Representative | Named in identifying information |
| Joseph Whitney | Administrator | Named in identifying information |
| Elizabeth Gregory-Weil | Licensing Consultant | Author of the inspection report |
| Employee 3 | Explained medication refill issues and acknowledged medication discontinuation |
Inspection Report
Original Licensing
Capacity: 94
Deficiencies: 0
Jan 20, 2005
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Waltonwood at Twelve Oaks II.
Findings
The facility was found to be in substantial compliance with licensing requirements, resulting in the issuance of a temporary license with a maximum capacity of 94 beds. The facility is newly constructed, barrier free, and designed to serve aged individuals including those with Alzheimer's disease.
Report Facts
Maximum licensed capacity: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Loma M Campbell | Licensing Staff | Author of the licensing study report and contact person. |
| Jean Brace | Authorized Representative | Named as authorized representative of the facility. |
| Colleen DeBard | Administrator | Named as facility administrator. |
| Betsy Montgomery | Area Manager | Approved the licensing study report. |
Loading inspection reports...
