Inspection Reports for
Allegria Village

R 325.1931 Employees; general provisions: Resident A’s service plan had not been updated since 1/30/2025. Resident A’s room was dirty and smelled of urine. Resident A’s care needs were not being met.

R 325.1932 Resident medications: Resident A repeatedly refused prescribed medications in December, January, and February, and the facility did not contact the appropriate licensed health care professional as required.

R 325.1931 Employees; general provisions: The facility failed to timely implement the physician-ordered bed rails by attaching them to Resident A’s bed as identified on the 11/09/2025 Incident Report.

R 325.1944 Employee records and work schedules: schedules provided by the facility were not updated to reflect staffing changes on numerous days/shifts for the timeframe reviewed.

MCL 333.20201 Policy describing rights and responsibilities of patients or residents; adoption; posting and distribution; contents; additional requirements; discharging, harassing, retaliating, or discriminating against patient exercising protected right; exercise of rights by patient's representative; informing patient or resident of policy; designation of person to exercise rights and responsibilities; additional patients' rights; definitions. (2)(e) A patient or resident is entitled to receive adequate and appropriate care. R 325.1921 Governing bodies, administrators, and supervisors. (1)(b) Assure that the home maintains an organized program to provide room and board, protection, supervision, assistance, and supervised personal care for its residents. Based on the review of call light response times, residents frequently had to wait more than 20 minutes for a caregiver to respond to their request for assistance.

MCL 333.20201 Policy describing rights and responsibilities of patients or residents: a resident was asked to sign a do not resuscitate (DNR) form in a public space with other residents nearby, violating confidentiality.

R 325.1921 Governing bodies, administrators, and supervisors: Resident D’s service plan was incomplete and lacked specific care, maintenance, and instructions for supervised personal care.

R 325.1922 Admission and retention of residents: The facility lacked an annual Tuberculosis risk assessment.

R 325.1931 Employees; general provisions: The facility lacked identification of one shift supervisor of resident care as medication technicians were supervisors.

R 325.1932 Resident medications: Service plans for Residents A, B, C, D, and F lacked identification of medication management to be managed by the home.

R 325.1932 Resident medications: Medication administration records for Residents B, C, E, and F showed multiple missed or undocumented doses and lacked reasons for as needed medications.

R 325.1976 Kitchen and dietary: Food items in the memory care refrigerator were stored in plastic bags and fruit was covered but not dated.

R 325.1976 Kitchen and dietary: Residents’ refrigerators in rooms 214 and 231 lacked reliable thermometers.

R 325.1979 General maintenance and storage: Two oxygen tanks in room 231 were free-standing and not secured in a holder.

R 325.1931 Employees; general provisions: Employees #1 and #2 had not completed training in reporting, personal care, safety and fire prevention, and infectious disease/standard precautions.

R 325.1931 Employees; general provisions: Employee #3 had not completed training in reporting, safety and fire prevention, and infectious disease/standard precautions.

R 325.1921 Governing bodies, administrators, and supervisors: the facility failed to maintain an organized program ensuring proper oxygen administration and timely call light response for Resident A.

R 325.1921 Governing bodies, administrators, and supervisors: the home did not assure an organized program of protection on 1/29/2024 when Resident A was left in the dining room during dinner meal with no caregiver staff present to address her choking.

R 325.1922 Admission and retention of residents: Resident A’s service plan was not updated after having a choking incident to address the significant change in Resident A’s care needs including the diagnosis of dysphagia, the physician’s order for a speech evaluation to treat the dysphagia, and the hospital discharge instructions of how to prevent another choking incident.

R 325.1935 Bedding, linens, and clothing: the facility primarily depends on residents to provide their own linens and does not maintain a sufficient supply of extra linens to ensure availability when residents' linens are being washed.

R 325.1922 Admission and retention of residents: Resident B’s service plan did not include any instruction or information pertaining to his need for wound care.

F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to provide effective communication methods for resident R89 who speaks Arabic, resulting in language barriers and resident frustration.

F 0658 Ensure services provided by the nursing facility meet professional standards of quality: the facility failed to follow standards of practice for medication administration for resident R89, holding medications without physician orders and failing to notify the physician.

F 0759 Ensure medication error rates are not 5 percent or greater: the facility had a 26.47% medication error rate due to multiple errors including holding medications without orders and failing to administer available medications.

F 0760 Ensure that residents are free from significant medication errors: resident R89 missed three doses of a prescribed inhaler due to transcription errors and failure to administer medication as ordered.

F 0658 Ensure services provided by the nursing facility meet professional standards of quality: medications were held without physician's orders and a medication order was not correctly transcribed on the Medication Administration Record.

F 0759 Ensure medication error rates are not 5 percent or greater: the facility had a 26.47% medication error rate due to withheld medications without orders, missing medications not located, and failure to notify appropriate staff.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility failed to repair a hole in the floor near Resident R291's bed, creating a tripping hazard and infection control concern.

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason: the facility failed to provide toilet transfer assistance to Resident R291, resulting in unmet care needs and resident dissatisfaction.

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: the facility served cold and visually unappealing meals to residents R7, R9, and R22, with a broken heating system not repaired for two years.

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: the facility failed to provide pneumococcal and influenza vaccinations or education to residents R4, R18, and R25.

F 0887 Educate residents and staff on COVID-19 vaccination and offer the vaccine: the facility failed to provide COVID-19 vaccinations or education to residents R4 and R18.

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable: the facility failed to maintain functional equipment and a sanitary 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 and ice machines, and malfunctioning handwashing faucets.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide adequate supervision for one resident with impaired cognition who was left unattended during an outside appointment, resulting in potential heat exposure and risk of being struck by a vehicle.

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: meals served to residents in rooms were cold and visually unappealing due to tightly wrapped saran wrap causing condensation and mashed food, with a broken heating system not maintaining food temperature.

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: multiple residents reported disliking the food temperature and quality, with some skipping meals.

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable: the facility failed to maintain functional equipment and a sanitary environment including heavily soiled and worn carpeting, broken dish machine, missing freezer door gasket, broken food heating system, detached floor ceiling plate, soiled ceiling vents, broken coffee machine, non-functioning ice machine, and malfunctioning hand washing sinks.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide scheduled showers for residents R506 and R508 for the last 30 days, despite scheduled shower days.

F 0580 Immediate notification: the facility failed to notify the resident's family of a fall for one resident (R603).

F 0684 Appropriate treatment and care: the facility failed to properly assess (obtain vital signs and complete neurological checks) after a reported, unwitnessed fall for one resident (R603) on anti-coagulant therapy, resulting in hospitalization for a brain bleed and subsequent death.

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. The facility failed to notify the court appointed legal guardian/family member before discharging Resident #325, resulting in the guardian being unaware of the discharge and location.

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. The facility failed to notify the court appointed legal guardian/family member before discharging Resident #325, resulting in the guardian being unaware of the discharge and relocation plans.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. The facility failed to assess the effectiveness of administered anti-diarrheal medication and communicate incidents of loose stools/diarrhea for Resident #32, resulting in untreated diarrhea and resident frustration.

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. The facility failed to properly secure indwelling catheter tubing for Resident #40, resulting in potential for genital trauma.

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. The facility failed to properly monitor refrigerator temperature, date opened insulin pens, and refrigerate unopened insulin pens, risking administration of unsafe and ineffective medications.

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. The facility failed to maintain an effective pest control program to ensure the facility is free of pests, resulting in live flies observed in multiple kitchen and waste areas and increased potential for contamination and foodborne illness.