STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS LANSING. AH A Henry Ford Village Assisted Living Facility

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STATE OF MICHIGAN RICK SNYDER

GOVERNOR DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS LANSING

SHELLY EDGERTON DIRECTOR

611 W. OTTAWA • P.O. BOX 30664 • LANSING, MICHIGAN 48909 www.michigan.gov/lara • 517-335-1980

August 3, 2018 Heather Scott

Henry Ford Village Assisted Living Facility 15101 Ford Road

Dearborn, MI 48126

RE: License #:

Investigation #:

AH820236806 2018A1011026

Henry Ford Village Assisted Living Facility

Dear Ms. Scott:

Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan is required. The corrective action plan is due 15 days from the date of this letter and must include the following:

• How compliance with each rule will be achieved.

• Who is directly responsible for implementing the corrective action for each violation.

• Specific time frames for each violation as to when the correction will be completed or implemented.

• How continuing compliance will be maintained once compliance is achieved.

• The signature of the authorized representative and a date.

If you desire technical assistance in addressing these issues, please feel free to contact me. In any event, the corrective action plan is due within 15 days. Failure to submit an acceptable corrective action plan will result in disciplinary action.

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Please review the enclosed documentation for accuracy and contact me with any questions. In the event that I am not available and you need to speak to someone immediately, please contact the local office at (248) 975-5053.

Sincerely,

Andrea Krausmann, Licensing Staff

Bureau of Community and Health Systems 4th Floor, Suite 4B

51111 Woodward Avenue Pontiac, MI 48342

(586) 256-1632 Enclosure

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1 MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

BUREAU OF COMMUNITY AND HEALTH SYSTEMS SPECIAL INVESTIGATION REPORT

I. IDENTIFYING INFORMATION

License #: AH820236806

Investigation #: 2018A1011026 Complaint Receipt Date: 06/07/2018 Investigation Initiation Date: 06/07/2018 Report Due Date: 08/07/2018

Licensee Name: Henry Ford Village Inc.

Licensee Address: 15101 Ford Rd.

Dearborn, MI 48126 Licensee Telephone #: (313) 584-1000 Administrator: Heather Scott Authorized Representative: Heather Scott

Name of Facility: Henry Ford Village Assisted Living Facility Facility Address: 15101 Ford Road

Dearborn, MI 48126 Facility Telephone #: (313) 584-1000 Original Issuance Date: 08/01/1999

License Status: REGULAR

Effective Date: 07/08/2017 Expiration Date: 07/07/2018

Capacity: 132

Program Type: ALZHEIMERS

AGED

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II. ALLEGATION(S)

III. METHODOLOGY

06/07/2018 Special Investigation Intake 2018A1011026

06/07/2018 Special Investigation Initiated - Telephone Interviewed complainant via telephone.

06/07/2018 APS Referral

Submitted Adult Protective Services (APS) Centralized Intake Unit.

06/07/2018 Contact - Document Received

Confirmation that my APS referral was received.

06/07/2018 Contact - Telephone call received APS Supervisor Rodney Steed.

07/30/2018 Inspection Completed On-site

Observations made, interviews conducted.

07/31/2018 Inspection Completed On-site

Observations made, interview conducted.

07/31/2018 Exit Conference

Conducted with authorized representative/administrator Heather Scott while on-site.

ALLEGATION:

On 6/5/18 at 9:30 am, Resident A's bathroom was observed with feces on the toilet seat, wastebasket filled with soiled briefs and two stains on the carpet that appeared to be smeared feces.

Violation Established?

On 6/5/18 at 9:30 am, Resident A's bathroom was observed with feces on the toilet seat, wastebasket filled with soiled briefs and two stains on the carpet that appeared to be smeared feces.

Yes

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INVESTIGATION:

On 6/7/18, the allegations including photographs were received via the department’s on-line complaint intake unit.

On 6/7/18, I interviewed the complaint by telephone. The complainant explained that Resident A lives on the third floor memory care unit and Resident A requires staff assistance with toileting. The complainant said the issues were immediately brought to the attention of third floor supervisor, Shondra Pritchet, and the items were

addressed that day.

On 6/7/18, I emailed a referral to adult protective services (APS). APS supervisor Rodney Steed then called to inform me that the referral will not be assigned for investigation.

On 7/30/18, the facility’s authorized representative/administrator Heather Scott and I went to Resident A’s room on the third floor. We observed the facility’s contracted housekeeping company staff, Travon Lever, in process of cleaning Resident A’s room. Resident A’s bathroom including the toilet was clean. The waste basket had been emptied and Mr. Lever was sweeping the bedroom carpet with a broom. Mr.

Lever said he has worked at the facility since May 2018, generally five days a week.

Mr. Lever affirmed that he is responsible for cleaning the carpet of any spills, using a carpet washing machine. Mr. Lever explained that the housekeeping company cleans the resident rooms in the home for the aged five days a week, Monday through Friday. On weekends, the housekeeping company cleans other areas on the Henry Ford Village campus. However, if there was a spill here in the home for the aged on the weekend, the housekeeping company staff will come in and wash the carpet. Mr. Lever said he has been called to this room before to complete such.

I observed a dried white spill on Resident A’s brown carpet and asked whether it required carpet cleaning. Mr. Lever replied that it did need washing and that he would be back to complete such.

On 7/31/18, I returned to Resident A’s room and discovered the dried white spill on the brown carpet was still in place. It did not appear that Mr. Lever washed the carpet. However, Resident A’s bathroom was clean and the waste basket had been emptied.

On 7/30/18, I interviewed Relative B1 at the facility. Relative B1 visits Resident B every day, in a third-floor room down the hall from Resident A. Relative B1 said,

“Today I had to take wet sheets off the bed. If I’m here, I change the sheets. They don’t put a pad on the sheets. The room and bathroom they do pretty good. The guy today doesn’t do as well [cleaning] as the other guy. But the other guy filled in yesterday and it was cleaned. A good month or month and a half ago, for a week or two the toilet was brown. But since then, it’s been clean. They do clean the carpet.

If anything gets on it, they come right in to get it in shape. But I do the dusting in

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here.” I observed Resident B’s bathroom to be clean and the wastebasket empty.

Resident B’s carpet appeared in need of vacuuming with bits of debris on the carpet.

On 7/30/18, I interviewed Relative C1 at the facility. Relative C1 visits Resident C on the third floor almost every day or every other day. Relative C1 explained there have been problems with Resident C’s bathroom not being cleaned. Relative C1 said “Today there was feces on his toilet seat and on his clothing. It was hard on the toilet. I had to scrub it off.” Relative C1 explained Resident C uses a urinal and will spill it accidentally. The housekeeping staff will only clean the immediate spill spot and consequently, “The whole room smelled of rhinoceros pee.” Relative C1

purchased a carpet washing machine and now has a family member clean Resident C’s carpet once a month. I observed Resident C’s bathroom to be clean but Relative C1 had cleaned it. The wastebasket was empty.

APPLICABLE RULE

R 325.1979 General maintenance and storage.

(1) The building, equipment, and furniture shall be kept clean and in good repair.

ANALYSIS: On 7/30/18, a dried white spill was observed on Resident A’s carpet and it was discussed with housekeeping staff Travon Lever. Mr. Lever indicated he would wash the carpet. On 7/31/18, the dried white spill was observed again. The carpet did not appear to have been washed.

Resident B’s and Resident C’s family members who visit regularly, detailed incidents of their residents’ rooms not being kept clean.

CONCLUSION: VIOLATION ESTABLISHED

On 7/31/18, I conducted an exit conference with authorized representative/administrator Heather Scott at the facility.

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5 IV. RECOMMENDATION

Contingent upon receipt of an acceptable corrective action plan, it is recommended that the status of the license remain unchanged.

8/1/2018

________________________________________

Andrea Krausmann Licensing Staff

Date

Approved By:

8/2/18

________________________________________

Russell B. Misiak Area Manager

Date

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