Inspection Reports for
Allegria Village
15101 Ford Rd, Dearborn, MI 48126, United States, MI, 48126
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.6 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
65% worse than Michigan average
Michigan average: 5.2 deficiencies/year
Deficiencies per year
32
24
16
8
0
Occupancy
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 rate over time
Inspection Report
Routine
Deficiencies: 2
Date: Nov 20, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medication administration standards and to assess medication error rates in the nursing facility.
Findings
The facility failed to follow professional standards for medication administration, resulting in medications being held without physician orders and transcription errors. The medication error rate was 26.47%, exceeding the acceptable threshold of 5%.
Deficiencies (2)
F 0658: The facility failed to follow standards of practice for medication administration by holding medications without physician orders and failing to transcribe a medication order on the Medication Administration Record.
F 0759: The facility failed to maintain a medication error rate below 5%, with a 26.47% error rate observed due to withheld medications without orders, missing medications not located, and transcription errors.
Report Facts
Medication error rate: 26.47
Medication administration opportunities: 34
Medication errors observed: 9
Medications withheld without order: 3
Medications not given due to unavailability: 3
Medications not administered due to missing stock: 3
Consecutive days medication not given: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Held medications without physician orders and failed to locate missing medications |
| RN E | Director of Nursing and Nurse Unit Manager Registered Nurse | Interviewed regarding medication holds and transcription errors; inspected medication cart |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure effective communication for a resident with a language barrier and concerns about medication administration practices.
Complaint Details
The complaint investigation focused on communication barriers for a resident who spoke Arabic and medication administration errors. The resident's communication needs were not properly assessed or addressed, and multiple medication errors were documented, including holding medications without orders and transcription omissions.
Findings
The facility failed to provide effective communication methods for a resident who spoke Arabic, resulting in language barriers and resident frustration. Additionally, the facility failed to follow professional standards in medication administration, including holding medications without physician orders, transcription errors on the Medication Administration Record, and a medication error rate exceeding 5%.
Deficiencies (4)
F 0550: The facility failed to ensure an effective means of communication was established in a timely manner for one resident with a language barrier, resulting in communication difficulties and resident frustration.
F 0658: The facility failed to follow professional standards for medication administration for one resident, including holding medications without physician orders and transcription errors on the Medication Administration Record.
F 0759: The facility failed to maintain a medication error rate below 5%, with nine errors observed from 34 opportunities, including withholding medications without orders and failure to locate missing medications.
F 0760: The facility failed to ensure one resident was free from significant medication errors, resulting in three missed doses of a prescribed inhaler due to transcription errors.
Report Facts
Medication error rate: 26.47
Medications held without orders: 3
Missed medication doses: 3
Medications not given due to unavailability: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Held medications without physician orders and failed to administer prescribed medications. |
| RN E | Registered Nurse/Unit Manager | Confirmed transcription errors and medication administration issues during interviews. |
| SLP F | Speech Language Pathologist | Arabic-speaker who interviewed the resident and confirmed communication barriers. |
| SW G | Social Worker | Completed BIMS evaluation but did not interview resident due to language barrier. |
| DON | Director of Nursing | Acknowledged failures in communication assessment and medication administration. |
| NHA | Nursing Home Administrator | Reviewed clinical records and acknowledged concerns about communication and care planning. |
| Assistant Administrator C | Assistant Administrator | Confirmed limited availability of Arabic-speaking staff during specified period. |
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
Deficiencies: 3
Date: Aug 22, 2024
Visit Reason
The inspection was conducted following complaints regarding inadequate supervision of a cognitively impaired resident during an offsite appointment, cold and unpalatable food served to residents eating in their rooms, and unsafe, unsanitary, and poorly maintained facility conditions including broken equipment and soiled carpeting.
Complaint Details
The complaint investigation was triggered by reports of inadequate supervision of a cognitively impaired resident during an offsite appointment, cold food complaints from residents eating in their rooms, and concerns about facility cleanliness and equipment maintenance. The supervision complaint was substantiated with findings of the resident being left unattended and found walking along a highway. Food and environmental concerns were confirmed through resident interviews, observations, and record reviews.
Findings
The facility failed to provide adequate supervision for a resident with impaired cognition during an offsite appointment, resulting in potential harm. The facility also failed to provide palatable, properly heated meals to residents eating in their rooms. Additionally, the facility did not maintain a safe, clean, and functional environment, with issues including heavily soiled carpeting, broken kitchen equipment, and unsanitary conditions in kitchenettes.
Deficiencies (3)
F 0689: The facility failed to provide adequate supervision for one resident with impaired cognition during an offsite appointment, resulting in potential exposure to heat and risk of being struck by a vehicle.
F 0804: The facility failed to provide palatable, attractive, and safely heated meals to three residents eating in their rooms, resulting in cold and visually unappealing food.
F 0921: The facility failed to maintain a safe, clean, and functional environment, including heavily soiled and worn carpeting, broken kitchen equipment, unsanitary ceiling vents, and malfunctioning faucets, affecting all residents.
Report Facts
Resident BIMS score: 11
Resident BIMS score: 13
Resident BIMS score: 15
Food temperatures: 103.2
Food temperatures: 110
Food temperatures: 83
Food temperatures: 53.2
Facility residents affected: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding supervision of resident R77 and acknowledged supervision was required. | |
| Nursing Home Administrator | Interviewed about resident R77 found walking along highway and about broken equipment and food heating system. | |
| Supervisor A | Dining Supervisor | Reported broken heating system for food and food complaints. |
| Maintenance Director E | Interviewed about carpet cleaning responsibilities. | |
| Housekeeping Director C | Interviewed about carpet cleaning rotation and housekeeping responsibilities. |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 22, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory standards related to resident safety, care, environment, food service, immunizations, and facility maintenance.
Findings
The facility was found deficient in maintaining a safe and clean environment, providing adequate assistance with activities of daily living, ensuring palatable and properly heated food, and documenting and offering required immunizations. Multiple equipment and environmental issues were noted, including a hole in resident flooring, broken heating system for food, soiled carpeting, and malfunctioning kitchen equipment.
Deficiencies (6)
F 0584: The facility failed to provide a safe, clean, and homelike environment, evidenced by a four by eight-inch hole in the floor near resident R291's bed, creating a tripping hazard and infection control concern.
F 0676: The facility failed to provide toilet transfer assistance to resident R291, resulting in unmet care needs and resident dissatisfaction.
F 0804: The facility failed to provide palatable meals at safe temperatures, with residents R7, R9, and R22 reporting cold and visually unappealing food served in rooms due to a broken heating system.
F 0883: The facility failed to ensure residents R4, R18, and R25 were provided pneumococcal and influenza vaccinations and education, risking potential spread of disease.
F 0887: The facility failed to provide COVID-19 vaccination education and offer to residents R4 and R18, risking potential spread of COVID-19.
F 0921: The facility failed to maintain a safe, clean, and functional environment, including heavily soiled and worn carpeting, broken kitchen equipment, missing freezer gaskets, broken heating system for food, detached floor ceiling plate, soiled ceiling vents, broken coffee machine, malfunctioning ice machine, and faulty hand washing faucets.
Report Facts
Fall risk assessment score: 19
BIMS score: 15
Food temperature: 103.2
Food temperature: 110
Food temperature: 83
Food temperature: 53.2
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse G | Licensed Practical Nurse | Interviewed regarding awareness of floor hole and toilet assistance for resident R291 |
| Maintenance Director E | Maintenance Director | Interviewed regarding floor hole, maintenance audits, and facility equipment issues |
| Director of Nursing | Director of Nursing | Interviewed regarding floor hole, toilet assistance, immunization deficiencies, and facility concerns |
| Certified Nursing Assistant H | Certified Nursing Assistant | Documented lack of toilet assistance to resident R291 |
| Certified Nursing Assistant K | Certified Nursing Assistant | Documented set up help for resident R291 |
| Occupational Therapy Assistant I | Occupational Therapy Assistant | Interviewed regarding resident R291's transfer needs |
| Physical Therapy Assistant J | Physical Therapy Assistant | Interviewed regarding resident R291's transfer needs |
| Supervisor A | Dining Supervisor | Interviewed regarding broken heating system and food complaints |
| Housekeeping Director C | Housekeeping Director | Interviewed regarding carpet cleaning and housekeeping responsibilities |
| Infection Preventionist D | Infection Preventionist | Interviewed regarding immunization documentation and deficiencies |
| Administrator | Administrator | Interviewed regarding broken equipment and facility maintenance concerns |
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
Complaint Investigation
Deficiencies: 1
Date: May 2, 2024
Visit Reason
The inspection was conducted due to a complaint intake (MI00143709) regarding failure to provide scheduled showers for residents, potentially impacting hygiene and dignity.
Complaint Details
This citation pertains to intake number MI00143709. The complaint was substantiated based on interviews and record reviews showing failure to provide scheduled showers for two residents.
Findings
The facility failed to provide scheduled showers or bed baths for two residents (R506 and R508) over the last 30 days, resulting in potential unmet hygiene needs, loss of dignity, and emotional distress. Documentation of showers was missing despite scheduled shower days and staff interviews confirming expected procedures.
Deficiencies (1)
F 0677: The facility failed to provide scheduled showers or bed baths for residents R506 and R508 for the last 30 days, resulting in potential unmet hygiene needs and emotional distress.
Report Facts
Residents reviewed for ADLs: 3
Residents affected: 2
BIMS score: 8
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) C | Reported nurse should complete skin observation on scheduled shower days | |
| Unit Manager D | Reported showers should be documented in POC and nurses should complete skin assessments | |
| CNA E | Reported showers are documented in the POC | |
| Unit Manager F | Reported showers are documented by CNAs in POC and nurses document showers on skin assessments | |
| Director of Nursing (DON) | Reported showers are documented by CNAs in POC and nurses complete skin assessments; no shower documentation found for R506 or R508 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 7, 2024
Visit Reason
The inspection was conducted following a complaint intake MI00142789 regarding the facility's failure to notify a resident's family about a fall and to properly assess the resident after the fall.
Complaint Details
This complaint investigation pertains to intake MI00142789. The complaint alleged failure to notify family of a fall and failure to properly assess the resident after the fall. The complaint was substantiated as the facility did not notify the family and failed to perform required neurological checks and vital sign monitoring.
Findings
The facility failed to notify the family of resident R603's fall and subsequent hospitalization for a brain bleed. Additionally, the facility did not perform appropriate neurological checks or vital sign monitoring after the fall, which contributed to the resident's adverse outcome and death.
Deficiencies (2)
F 0580: The facility failed to inform the family of resident R603's fall and hospital transfer. The family was not notified despite facility policy requiring notification.
F 0684: The facility failed to properly assess resident R603 after an unwitnessed fall by not obtaining vital signs or completing neurological checks. This resident was on anticoagulant therapy and later died from a brain bleed.
Report Facts
Medication dosage: 5
Medication administration dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reported family notification policy and confirmed family was not notified of fall |
| Nursing Home Administrator A | Nursing Home Administrator | Reported no neurological checks were performed on resident R603 after fall |
| Licensed Practical Nurse C | Licensed Practical Nurse | Reported shift report details and monitoring of resident R603 after fall |
| Certified Nursing Assistant E | Certified Nursing Assistant | Reported resident R603's fall and communicated to nursing staff |
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
Deficiencies: 5
Date: Aug 7, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident discharge notification, medication administration, catheter care, medication storage, and pest control at Allegria Village nursing home.
Findings
The facility failed to notify a legal guardian before discharging a resident, assess and communicate the effectiveness of anti-diarrheal medication, properly secure urinary catheter tubing, monitor medication storage temperatures and label insulin pens correctly, and maintain an effective pest control program, resulting in potential risks to residents' health and safety.
Deficiencies (5)
F 0623: The facility failed to notify the court-appointed legal guardian before discharging Resident #325, resulting in the guardian being unaware of the resident's relocation and not involved in discharge planning.
F 0684: The facility failed to assess the effectiveness of anti-diarrheal medication and communicate incidents of loose stools for Resident #32, resulting in untreated diarrhea and resident frustration.
F 0690: The facility failed to properly secure indwelling catheter tubing for Resident #40, resulting in potential genital trauma.
F 0761: The facility failed to monitor the temperature of a medication refrigerator, properly date opened insulin pens, and refrigerate unopened insulin pens, risking administration of unsafe medications.
F 0925: The facility failed to maintain an effective pest control program, resulting in live flies observed in multiple kitchen and waste areas, increasing risk of contamination and foodborne illness.
Report Facts
Residents affected: 59
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 3
Temperature out of range: 29
Medication storage temperature range: 31
Medication storage temperature range: 41
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 7, 2023
Visit Reason
The inspection was conducted due to a complaint intake (MI00133266) regarding failure to notify the court-appointed legal guardian/family member before discharging a resident from the facility.
Complaint Details
This citation pertains to Intake #MI00133266. The complaint was substantiated based on interviews and record reviews confirming failure to notify the legal guardian prior to discharge.
Findings
The facility failed to notify the legal guardian/family of Resident #325 before discharging the resident to a friend's home, resulting in the guardian being unaware of the discharge location and not involved in discharge planning. The facility policy requires informing the family of discharge plans and providing discharge instructions if the resident is discharged home.
Deficiencies (1)
F 0623: The facility failed to provide timely notification to the resident's legal guardian/family before discharge, resulting in the guardian being unaware of the discharge location and not involved in discharge planning.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Interviewed regarding discharge notification attempts for Resident #325 |
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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