Allegria Village

Inspectors wroteThis citation pertains to intake 2807638. Based on interview and record review the facility failed to ensure adequate supervision for one resident (R907) out of three residents reviewed for elopement. As a result, R907 eloped from the facility, placing R907 at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective means of communication was established in a timely manner for one resident (R89) out of one resident reviewed for communication, resulting in language barriers and resident frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice for one (R89) of five residents reviewed for Medication Administration resulting in R89 having medications held without a physician's orders and one medication order not being correctly transcribed on the Medication Administration Record.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a medication error rate below 5%.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (R89) of four residents reviewed for Medication Administration was free from a significant medication error resulting in R89 missing three doses of a prescribed inhaler; Tiotropium 2.5 MCG (microgram)/ACT (breath actuated) inhaler.

Inspectors wroteBased on observation, interview and record review the facility failed to provide meals that were palatable for three residents (R7, R9 and R22) out of three resident that consumed meals in rooms, resulting in cold and visually unappealing foods. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings Include: R9 On 8/20/2024 at 11:20 AM, R9 was quiered about meals. R9 said, that he does not care for the food and often skips meals. R9 explained, sometimes the food is cold and it does not taste that good. Record review revealed R9 was admitted into facilty on 7/26/24 with a pertinent diagnosis of Type ll diabetes. According to Brief Interview for Mental Status, (BIMS) dated 8/1/24, R9 scored of 15 out of 15 (intact cognition). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain functional equipment and a sanitary environment 1) Replace the floor carpeting of the halls on the first, second and third floor of the facility 2) Clean the ceiling air vents in three kitchenettes, 3) replace and or repair the broken heating system for resident's food and 4) Ensure functional water faucets were attached to the hand washing sinks properly. These deficient practices had the potential to affect all 69 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean and comfortable environment for one resident (R291) out of one resident reviewed for safe, clean, homelike environment resulting in resident dissatisfaction and a tripping hazard.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a toilet transfer for one resident (R291) of four residents reviewed who were dependent on staff for performance of activities of daily living (ADLs), resulting in unmet care needs and resident dissatisfaction.

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (R4, R18, and R25) out of five residents reviewed for immunizations were provided pneumococcal and influenza vaccination and education, resulting in the potential for development and spread of influenza and pneumonia among vulnerable residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (R4 and R18) out of five residents reviewed for immunizations were provided Covid-19 vaccinations and education resulting in the potential for development and spread of Covid-19 among vulnerable residents in the facility.

Inspectors wroteThis citation pertains to intakes MI00146255 and MI00146314. Based on interview and record review the facility failed to provide adequate supervision for one resident (R77) out of one resident reviewed for elopement, resulting in the potential for heat exposure and being struck by a motor vehicle when R77 left an appointment unsupervised.

Inspectors wroteThis citation pertains to intake numbers MI00143709. Based on interview and record review, the facility failed to provide scheduled showers for two residents (R506 and R508) out of three residents reviewed for activities of daily living (ADL's), resulting in the potential for unmet hygiene needs, loss of dignity, and emotional distress.

Inspectors wroteThis citation pertains to intake MI00142789. Based on interview and record review, the facility failed to properly assess (obtain vital signs and complete neurological checks) after a reported, unwitnessed fall for one resident (R603) out of six residents reviewed for falls. R603 was on anti-coagulant therapy. R603's fall was followed by hospitalization for a brain bleed and subsequent death.

Inspectors wroteThis citation pertains to intake MI00142789. Based on interview and record review, the facility failed to inform family of a fall for one resident (R603) of six residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 59 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to (1.) properly monitor the temperature of one medication storage refrigerator out of two refrigerators reviewed for medication storage, (2.) properly date two opened insulin pens stored in the medication cart, and (3.) failed to ensure an unopened insulin pen was refrigerated as indicated per manufacturer's instructions for one medication cart out of three medication carts reviewed for medication storage, resulting in the potential to administer unsafe, ineffective, and outdated medications.

Inspectors wroteThis citation pertains to Intake #MI00133266. Based on interview and record review, the facility failed to notify the court appointed legal guardian/family member before discharging out of the facility for one resident (R325) out of three residents reviewed for discharge, resulting in the guardian/family being unaware of where their loved one was relocated and not being involved in the discharge planning.

Inspectors wroteBased on interview and record review, the facility failed to assess the effectiveness of administered anti-diarrheal medication and communicate incidents of loose stools/diarrhea for one resident (R32) of one resident reviewed for diarrhea/constipation, resulting in resident frustration and incidents of loose stools/diarrhea going untreated.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly secure indwelling catheter tubing for one resident (R40) of three residents reviewed for urinary catheters, resulting in the potential for genital trauma.