Allegria Village

In the surveyor’s words

From the most serious findings on record at Allegria Village, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 7, 2024

  This 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. Findings include: Review of an Admission Record in the EHR (Electronic Health Record) revealed, R603 admitted to the facility on [DATE] with pertinent diagnoses which included chronic atrial fibrillation and abnormalities of gait and mobility. […]

• No harm, potential for more than minimal, widespreadF804Aug 22, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF921Aug 22, 2024

  Based 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. Findings include : On 8/20/24 at 9:00 A.M. through 8/22/24 at 3:20 P.M. the carpeting on the first, second and third floor was observed heavily soiled, stained and severely worn. Visible collections of dust and lint were noted around the edges of the flooring. […]

• No harm, potential for more than minimal, widespreadF925Aug 7, 2023

  Based 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. Findings include: On 8/1/23 at 10:12 AM, four live flies were observed in the kitchen's dishwashing area. On 8/1/23 at 10:19 AM, seven live flies were observed near the kitchen's janitors closet and waste receptacle holding area. Upon observation the surveyor inquired with Dining Director, staff D on the current state of the insects in this area to which they responded, I think they come in when they take out the trash and the doors are open. […]

• No harm, potential for more than minimal, patternF761Aug 7, 2023

  Based 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. Findings include: During an observation and interview on 8/2/2023 at approximately 9:18 a.m., the first-floor medication storage room refrigerator was observed with thick ice covering the top where ice trays were to be stored. […]