Inspection Reports for Allegria Village
15101 Ford Rd, Dearborn, MI 48126, United States, MI, 48126
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 27, 2025, found deficiencies related to inconsistencies between staff schedules and daily assignment sheets, though the facility was not understaffed as alleged. Earlier inspections showed a pattern of deficiencies involving resident care issues such as delayed call light responses, inconsistent oxygen administration, and failure to update service plans, as well as documentation problems and insufficient linens. Complaint investigations substantiated concerns about confidentiality breaches, supervision lapses during a choking incident, and care delays, but fines or enforcement actions were not listed in the available reports. Most complaints were substantiated, while some allegations such as understaffing and inadequate dental or wound care were not. The facility’s inspection history shows ongoing challenges with care coordination and documentation, with no clear trend of overall improvement or worsening.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
53% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 70
Capacity: 132
Deficiencies: 1
Date: May 27, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility was understaffed across all three shifts, including times when the midnight shift had only two staff working.
Complaint Details
The complaint alleged understaffing on all three shifts, including times when the midnight shift had only two staff working. The complaint was anonymous and did not provide specific dates or timeframes. The violation of understaffing was not established.
Findings
The investigation found that the facility was not understaffed as alleged, with staffing levels sufficient to meet resident needs. However, a violation was established due to numerous inconsistencies between staff schedules and daily assignment sheets, where schedules were not updated to reflect actual staffing changes.
Deficiencies (1)
Schedules provided by the facility were not updated to reflect staffing changes on numerous days/shifts.
Report Facts
Resident census: 70
Total capacity: 132
Dates with schedule inconsistencies: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Garcia | Administrator and Authorized Representative | Interviewed during inspection regarding staffing and schedule issues |
Inspection Report
Complaint Investigation
Capacity: 132
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The investigation was initiated due to a complaint alleging that the Resident of Concern (ROC) did not receive appropriate care, including delayed response to call lights and issues with oxygen delivery.
Complaint Details
The complaint alleged that the ROC did not receive appropriate care, including lack of timely oxygen delivery and delayed response to call lights. The complaint was substantiated as violations were established.
Findings
The investigation found that residents, including the ROC, frequently experienced excessive wait times for assistance, sometimes over 20 minutes. The ROC's oxygen needs were managed as 'as needed' per hospice orders, but portable oxygen tanks were not always readily available. The call light system had malfunctions and the facility had not been adequately monitoring response times.
Deficiencies (1)
Residents frequently had to wait more than 20 minutes for a caregiver to respond to their call light requests.
Report Facts
Capacity: 132
Call light response time: 20
Investigation initiation date: Sep 20, 2024
Complaint receipt date: Sep 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Garcia | Administrator/Authorized Representative | Interviewed regarding care concerns and call light response |
| Barbara P. Zabitz | Health Care Surveyor | Conducted the investigation and authored the report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the investigation report |
Inspection Report
Complaint Investigation
Capacity: 132
Deficiencies: 1
Date: Jul 3, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging lack of confidential treatment of resident medical documentation, specifically that a resident was asked to sign a do not resuscitate (DNR) document for another resident in a public area.
Complaint Details
Complaint received on 07/02/2024 alleged that on 06/30/2024, Associate 1 asked a resident to sign a DNR document for another resident in the dining room with other residents present. The complaint was substantiated.
Findings
The investigation confirmed the allegation that Associate 1 asked an unrelated resident to sign a DNR form in the dining area with other residents present, violating confidentiality rules. Corrective measures, including formal counseling of Associate 1, were taken by the facility.
Deficiencies (1)
Lack of confidential treatment of resident medical documentation when a resident was asked to sign a DNR form for another resident in a public area.
Report Facts
Capacity: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Garcia | Administrator | Administrator who disagreed with Associate 1's actions and confirmed corrective measures |
| Stephanie Russeau | Director of Nursing | Provided investigative documentation and statement regarding Associate 1 |
Inspection Report
Renewal
Census: 23
Capacity: 132
Deficiencies: 9
Date: Feb 27, 2024
Visit Reason
The inspection was conducted as a Renewal Licensing Study to assess compliance with licensing requirements and determine eligibility for license renewal.
Findings
The facility was found to be non-compliant with multiple rules including incomplete resident service plans, lack of annual tuberculosis risk assessment, absence of designated shift supervisors, medication management deficiencies, improper food storage, missing refrigerator thermometers, unsecured oxygen tanks, and incomplete staff training.
Deficiencies (9)
Resident D’s service plan was incomplete and lacked specific care instructions for supervised personal care.
Facility lacked an annual Tuberculosis (TB) risk assessment.
Facility lacked identification of one shift supervisor of resident care per shift.
Residents A, B, C, D, and F’s service plans lacked identification of medication management to be managed by the home.
Medication administration records for multiple residents had blank entries and lacked reasons for administration of as needed medications.
Food items in memory care refrigerator were stored without dates, violating food safety rules.
Residents’ refrigerators in rooms 214 and 231 lacked reliable thermometers.
Two oxygen tanks in room 231 were free-standing and not secured in a holder.
Employees #1, #2, and #3 had incomplete training records missing key topics such as reporting, personal care, safety and fire prevention, and infectious disease precautions.
Report Facts
Number of staff interviewed and/or observed: 15
Number of residents interviewed and/or observed: 23
Facility capacity: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Garcia | Administrator/Authorized Representative | Interviewed regarding facility operations and findings |
| Jessica Rogers | Licensing Consultant | Author of the inspection report and recommendation |
Inspection Report
Complaint Investigation
Capacity: 132
Deficiencies: 2
Date: Feb 27, 2024
Visit Reason
The inspection was conducted following a complaint alleging that Resident A lacked his oxygen and that call lights were not answered timely.
Complaint Details
Complaint was received on 2024-02-23 regarding Resident A's oxygen not being available during lunch and delayed call light responses. The complaint was substantiated based on interviews, record reviews, and observations.
Findings
The investigation substantiated that Resident A's oxygen administration was inconsistent, with confusion over physician orders and staff requiring re-education on oxygen equipment use. Additionally, call light response times on Resident A's floor exceeded facility expectations, and Resident A sometimes removed his nasal cannula requiring staff reminders.
Deficiencies (2)
Failure to maintain consistent and proper oxygen administration for Resident A, including lack of clear physician orders and staff re-education needs.
Call light response times exceeded facility expectations, with average response times significantly longer than the expected 15 minutes.
Report Facts
Capacity: 132
Call light response time (1st shift): 26.35
Call light response time (2nd shift): 29.97
Call light response time (3rd shift): 34.83
Oxygen liters ordered: 3.5
Oxygen liters adjusted: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Conducted the investigation and authored the report. |
| Jennifer Garcia | Authorized Representative/Administrator | Interviewed during the investigation and provided documentation and correspondence. |
Inspection Report
Complaint Investigation
Capacity: 132
Deficiencies: 2
Date: Feb 8, 2024
Visit Reason
The investigation was initiated due to allegations received on 02/07/2024 regarding a choking incident where no staff was present, mold and blood stains in a former resident's room, leaking ceiling causing mold, improper medication storage and administration, concerns about a resident's physical appearance, and lack of hot water affecting resident bathing.
Complaint Details
The complaint was received on 02/07/2024 from an anonymous source via Adult Protective Services alleging multiple issues including a choking incident with no staff present, mold and blood stains in a former resident's room, leaking ceiling, improper medication storage and administration, concerning physical appearance of Resident E, and lack of hot water for bathing. The choking incident and failure to update Resident A's service plan were substantiated; other allegations were not substantiated.
Findings
The investigation established a violation for lack of staff supervision during a choking incident on 01/29/2024 and failure to update Resident A's service plan after the incident. No violations were found regarding mold, medication storage and administration, resident E's care, or hot water availability beyond one day.
Deficiencies (2)
Resident A was left in the dining room during dinner with no caregiver staff present to address her choking incident.
Resident A’s service plan was not updated after the choking incident to address significant changes in care needs including diagnosis of dysphagia and related physician orders.
Report Facts
Facility capacity: 132
Complaint receipt date: Feb 7, 2024
Investigation initiation date: Feb 7, 2024
Report due date: Apr 8, 2024
Hot water outage duration: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Garcia | Authorized Representative/Administrator | Interviewed regarding choking incident and other allegations; participated in exit conference |
| Andrea Krausmann | Licensing Staff | Author of the Special Investigation Report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 132
Deficiencies: 2
Date: Jan 19, 2024
Visit Reason
The inspection was conducted as a special investigation following a complaint received from adult protective services alleging lack of adequate dental care for Resident A, lack of adequate wound care for Resident B, short staffing, and insufficient linens at the facility.
Complaint Details
Complaint alleged lack of adequate dental care for Resident A, lack of adequate wound care for Resident B, facility short staffed, and insufficient linens. Dental care, wound care, and staffing allegations were not substantiated. Insufficient linens allegation was substantiated. Additional finding of missing wound care instructions in Resident B's service plan was also substantiated.
Findings
The investigation found no violations regarding dental care for Resident A, wound care for Resident B, or staffing levels. However, a violation was established for insufficient linens as the facility did not maintain a sufficient supply of extra linens. Additionally, a violation was found for failure to update Resident B's service plan to include wound care instructions.
Deficiencies (2)
Facility did not maintain a sufficient supply of extra linens to ensure availability to residents.
Resident B's service plan did not include documented instruction or information regarding wound care needs.
Report Facts
Resident census: 61
Total capacity: 132
Complaint receipt date: Jan 18, 2024
Investigation initiation date: Jan 19, 2024
Report due date: Mar 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Garcia | Administrator/Authorized Representative | Interviewed regarding allegations and findings. |
| Aaron Clum | Licensing Staff | Conducted the investigation and authored the report. |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report. |
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 17, 2023
Visit Reason
The document serves as a renewal notification for the Home for the Aged license of Allegria Village, confirming substantial compliance with public health code and administrative rules over the past year.
Findings
An administrative review revealed substantial compliance with applicable regulations, resulting in the renewal of the facility's license for a 12-month period effective 03/31/2023.
Report Facts
License effective period: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Staff | Signed the renewal notification letter |
Inspection Report
Complaint Investigation
Capacity: 132
Deficiencies: 1
Date: Nov 18, 2022
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident A was provided inadequate care, including lack of bathing, dressing, housekeeping, and dietary adherence, especially during a COVID-19 quarantine period.
Complaint Details
The complaint alleged Resident A did not receive adequate care according to her service plan, including lack of bathing, dressing, housekeeping, and dietary adherence during a COVID-19 quarantine from 10/23/2022 to 11/02/2022. The violation for inadequate care was not established, but additional findings related to documentation were noted.
Findings
The investigation found no violation regarding inadequate care for Resident A, as staff provided reasonable alternatives during quarantine and maintained care consistent with the service plan. However, a violation was established due to failure to maintain shower sheet documentation for at least a month.
Deficiencies (1)
Failure to maintain shower sheet documentation for Resident A for at least a month.
Report Facts
Capacity: 132
Complaint Receipt Date: Nov 17, 2022
Investigation Initiation Date: Nov 17, 2022
Inspection Date: Nov 18, 2022
Quarantine Period: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jordan Houston | Administrator/Authorized Representative | Interviewed and provided additional information and documentation |
| Alyssa Pischel | Interim Director of Nursing | Interviewed regarding Resident A's care and facility policies |
| Tracy Rice | Interim Director of Nursing | Present during interview and confirmed statements about Resident A's care |
Inspection Report
Original Licensing
Capacity: 132
Deficiencies: 0
Date: Sep 10, 2021
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Allegria Village, a home for the aged facility.
Findings
The study determined substantial compliance with the home for the aged public health code and administrative rules. The facility was found to be suitable for licensing with a temporary 6-month license issued for a maximum capacity of 132 beds.
Report Facts
Capacity: 132
Fire Safety Inspection Dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Krausmann | Homes for the Aged Licensing Staff | Author of the licensing study report and recommendation |
| Samuel Tennenbaum | Authorized Representative | Applicant's authorized representative receiving technical assistance and involved in licensing process |
| Russell Misiak | Area Manager | Approved the licensing recommendation |
| Michael McCormick | Bureau of Fire Services State Fire Marshal Inspector | Conducted fire safety inspections and issued certification |
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