Inspection Reports for Community Village
3200 Hospital Rd, Saginaw, MI, 48603
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Capacity: 90
Deficiencies: 4
Date: Mar 27, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging improper treatment of Resident A, including failure to provide pain medication and issues with the call pendant system on the evening of 2025-03-18.
Complaint Details
Complaint alleged improper treatment of Resident A on 2025-03-18, including failure to respond to call pendant alerts, staff verbal abuse, and refusal to provide pain medication. The complaint was substantiated based on interviews with Resident A, EMS personnel, witnesses, and staff.
Findings
The investigation confirmed violations including staff verbally abusing Resident A, failure to respond promptly to call pendant alerts due to a faulty system, refusal to administer requested pain medication, and failure to update Resident A's service plan to reflect his current mobility status.
Deficiencies (4)
Staff yelled at Resident A and did not provide requested care.
Facility lacked an organized program of protection to ensure prompt response to call pendant alerts; call pendant system was faulty and unreliable.
Resident A did not receive requested pain medication despite being in severe pain.
Resident A's service plan was not updated to reflect his current mobility and ambulation status.
Report Facts
Facility capacity: 90
Medication administration time: 19.78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Robinson | Administrator | Interviewed regarding the complaint and incident |
| David Benjamin | Authorized Representative | Named in the report and involved in correspondence |
| Elizabeth Gregory-Weil | Licensing Staff | Conducted the investigation and authored the report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report |
Inspection Report
Complaint Investigation
Capacity: 90
Deficiencies: 2
Date: Feb 21, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that a resident did not receive adequate care after a fall, and that staff were not properly trained to provide this type of care.
Complaint Details
The complaint alleged that a resident fell and did not receive adequate care because staff delayed reporting the fall and were not trained to provide necessary care. The complaint was substantiated with violations established.
Findings
The investigation found that the resident was left in pain for several hours after a fall without proper notification to management or healthcare providers, and that staff lacked adequate training in emergency care and assessment skills. Violations were established related to failure to notify management and insufficient staff training.
Deficiencies (2)
Failure of staff to notify on-call manager or administrator after resident fall and injury.
Staff were not adequately trained to provide care needed for residents, including emergency situations.
Report Facts
Capacity: 90
Complaint Receipt Date: Feb 12, 2024
Investigation Initiation Date: Feb 21, 2024
Report Due Date: Apr 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barbara P. Zabitz | Health Care Surveyor | Author of the inspection report and licensing staff |
| Robin Rappley | Administrator | Facility administrator interviewed during investigation |
| David Benjamin | Authorized Representative | Authorized representative of the facility |
Inspection Report
Renewal
Capacity: 90
Deficiencies: 3
Date: Dec 8, 2023
Visit Reason
The inspection was conducted as a renewal licensing study for the facility to assess compliance with applicable rules and regulations.
Findings
The facility was found to be in non-compliance with rules related to tuberculosis screening for residents and employees, and failure to provide a documented quality review program consistent with regulatory requirements.
Deficiencies (3)
Facility was unable to provide a community risk assessment including residents for tuberculosis screening.
Facility was unable to provide a community risk assessment including staff for tuberculosis screening; two associates did not complete TB screening within required timeframe.
Facility was unable to provide documented evidence of a quality review program consistent with section 20175(8) of the act, MCL 333.20175, and the professional review function.
Report Facts
Capacity: 90
Staff interviewed/observed: 7
Residents interviewed/observed: 20
Date of initial occupational exposure for associates: Apr 5, 2020
Date of TB screening completion for associates: Apr 15, 2020
Inspection Report
Complaint Investigation
Census: 79
Capacity: 90
Deficiencies: 1
Date: Sep 27, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging that the facility was understaffed, with only three caregivers working to tend to 80 residents, some requiring Hoyer lifts.
Complaint Details
The complaint alleged insufficient staffing with only three caregivers for 80 residents, some requiring Hoyer lifts. The complaint was substantiated based on review of staff schedules, resident roster, and call pendant response data.
Findings
The investigation confirmed that the facility was understaffed, with repeated instances of fewer than the desired seven staff per shift and several shifts with as few as two or three staff. Call pendant response data showed nearly 700 instances of excessive response times out of over 1100 alerts, and management had not been reviewing these times until recently.
Deficiencies (1)
The facility is understaffed, failing to have adequate and sufficient staff on duty at all times to meet resident needs.
Report Facts
Resident census: 79
Facility capacity: 90
Call pendant alerts: 1100
Excessive response times: 700
Staff on duty: 3
Staff on duty: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robin Rappley | Administrator | Provided information on staffing levels, schedules, and call pendant response data; acknowledged staffing challenges |
Inspection Report
Original Licensing
Capacity: 90
Deficiencies: 0
Date: Feb 5, 2020
Visit Reason
The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Community Village, a home for the aged facility seeking licensure for 90 beds.
Findings
The study determined substantial compliance with applicable licensing statutes and administrative rules. The facility was found to be barrier-free, equipped with necessary safety features, and capable of providing assisted living services to residents over the age of 55.
Report Facts
Capacity: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Miller | Administrator | Administrator of Community Village |
| Aaron Clum | Licensing Staff | Conducted the licensing study and recommended license issuance |
| Russell B. Misiak | Area Manager | Approved the licensing study report |
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