RICK SNYDER GOVERNOR STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS LANSING SHELLY EDGERTON DIRECTOR November 27, 2017 Kelly Moran RE: License #: AH810354781 Dear Ms. Moran: Attached is the Renewal Licensing Study Report for the facility referenced above. This renewal licensing report covers the period between 6/18/2016 and 6/17/2017. You have submitted an acceptable written corrective action plan addressing the violations cited in the report. To verify your implementation and compliance with this corrective action plan: You are to submit documentation of compliance. 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 feel free to contact the local office at (810) 787-7031. Sincerely, Aaron L. Clum, Licensing Staff Bureau of Community and Health Systems 4809 Clio Rd. Flint, MI 48504 (517) 230-2778 611 W. OTTAWA P.O. BOX 30664 LANSING, MICHIGAN 48909 www.michigan.gov/lara 517-335-1980
MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS RENEWAL INSPECTION REPORT I. IDENTIFYING INFORMATION License #: Licensee Name: AH810354781 Senior Living Ann Arbor, LLC Licensee Address: Ste. 100 2200 Genoa Business Park Brighton, MI 48114 Licensee Telephone #: (248) 438-2200 Administrator/Authorized Representative: Name of Facility: Facility Address: Kelly Moran Facility Telephone #: (734) 944-6600 Original Issuance Date: 12/18/2015 Capacity: 40 Program Type: AGED ALZHEIMERS 2
II. METHODS OF INSPECTION Date of On-site Inspection(s): 11/22/2017 Date of Bureau of Fire Services Inspection if applicable: 10/26/15, 10/20/17 Inspection Type: Interview and Observation Worksheet Combination Date of Exit Conference: 11/22/2017 No. of staff interviewed and/or observed 8 No. of residents interviewed and/or observed 20 No. of others interviewed 0 Role Medication pass / simulated pass observed? Yes No If no, explain. Interviewed staff on procedures of administration. Medication(s) and medication records(s) reviewed? Yes No If no, explain. Resident funds and associated documents reviewed for at least one resident? Yes No If no, explain. No resident funds held in trust. Meal preparation / service observed? Yes No If no, explain. Fire drills reviewed? Yes No If no, explain. Interviewed staff regarding disaster plans. Water temperatures checked? Yes No If no, explain. Incident report follow-up? Yes IR date/s: N/A Corrective action plan compliance verified? Yes CAP date/s and rule/s: Number of excluded employees followed up? N/A 3
III. DESCRIPTION OF FINDINGS & CONCLUSIONS The facility was found to be in non-compliance with the following administrative rules. R 325.1932(1) Resident medications. Medication shall be given, taken, or applied pursuant to labeling instructions or orders by the prescribing licensed health care professional. A review of resident medication administration records (MAR) revealed that staff did not have sufficient instructions to safely administer as needed medications. For instance, one resident s MAR identified that they were prescribed two as needed pain medications. The prescription for MAPAP 325 mg read two tablets every four hours as needed. While this prescription is commonly prescribed for pain this was not specified and nor was the type of pain it was intended to treat. The prescription for their Ibuprofen 600 mg read one tablet every six hours as needed for pain. Similarly, this instruction omitted the specific type of pain the medication was intended to treat. In addition, guidance was not found as to whether one prescription should be administered over the other or whether they could be administered at the same time. R 325. 1979(3) General maintenance and storage. (3) Hazardous and toxic materials shall be stored in a safe manner. An inspection of a resident room revealed three free standing unsecured oxygen tanks. IV. RECOMMENDATION An acceptable corrective action plan has been received on 11/22/17. Renewal of the license is recommended. 11/27/17 Date Licensing Consultant 11/27/17 Date Area Manager 4
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