Altoona Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and policy review, the facility failed to provide a comfortable and homelike environment. The facility identified a census of 94 residents. Findings include: 1. Observations revealed the following: a. On 2/24/25 at 1:45 PM, a loud beeping sound audible in the hallway and in a resident's room with the door closed. b. On 2/24/25 at 1:47 PM, Hall A and B had an odor that smelled like urine. A large gray barrel had the lid partially off and garbage inside. Hall C had four wheelchairs, a linen cart, a weight chair, a Broda chair, a mechanical lift and carts with lids lined along the hallway. c. On 2/24/25 at 1:55 PM, a loud beeping sound continued in the ABC hall. d. On 2/24/25 at 2:09 PM, the loud beeping sound continued. e. On 2/24/25 at 2:32 PM, the loud beeping sound subsided. f. On 2/24/25 at 3:02 PM, Hall C had three wheelchairs, a broda chair, a weight chair, a linen cart, a mechanical lift, and a soiled linen cart parked along the handrail in the hallway. g. On 2/24/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on direct observation, clinical record review, and Resident and staff interview, the facility failed to provide the residents the assistance needed in order to complete their individual activities of daily living for 4 of 4 residents reviewed (Residents #3, #12, #58, and #84). The facility reported a census of 94. Findings include: 1. The Quarterly MDS for Resident #84, dated 01/28/2025, documented his brief interview for mental status (BIMS) score as 15, indicating intact cognition. It documented the following diagnoses: Heart failure, Hypertension, renal insufficiency, Cerebrovascular Event (Stroke), Seizure disorder, Malnutrition, Acute respiratory failure, muscle weakness, and difficulty in walking. It further documented the resident was dependent upon staff for transferring, ambulation, and personal cares. The Care Plan for Resident #84, last revised 02/03/2025, documented the resident required an assist of one person for personal cares and encouragement for oral hygiene. It instructed staff members…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and policy review, the facility failed to ensure staff appropriately and safely transferred three of five residents observed during transfers (Resident #12, #19 and #84). The facility also failed to ensure cigarettes kept in a secure location for one of two residents reviewed for smoking (Resident#79). The facility also failed to reduce clutter in six of six hallways to create a homelike environment, and to ensure clear hallways for the residents to easily move throughout the facility without obstacles. The facility identified a census of 94 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had diagnoses of osteoporosis, dementia and bipolar disorder. The MDS documented the resident had 2 or more falls without injury. The MDS indicated the resident had impaired range of motion to bilateral lower extremities, and required substantial to maximum assistance for transfers. The Care Plan revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, document review, facility assessment, resident and staff interviews, the facility failed to provide sufficient nursing staff to meet the residents' needs safely, in a timely manner and that promotes each resident's rights, physical, mental, and psychosocial well-being. The facility reported a census of 94 residents. Findings include: Observation of breakfast dining on 2/25/25 revealed the following: 8:30 AM, twenty-four residents were sitting in one of the facility's two dining rooms, dietary staff noted to be plating resident's food from a steam table. 8:39 AM, twenty-one of twenty-four residents had been served, three residents sat at an assisted feeding table had not been served their breakfast. 8:42 AM, a Certified Nursing Assistant (CNA) entered the dining room and assisted one male resident with feeding. Staff A, Registered Nurse (RN) assisted the second male resident with feeding. 8:46 AM, the third male resident, sat with his eyes closed, had his food sitting in front of him and not eating. 8:47 AM, Staff L, Assistant Director of Nursing (ADON) entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification survey. The facility reported a census of 94 residents. Findings include: Review of facility's CMS 2567 from a recertification and complaint surveys on 4/11/24, 2/13/24, 12/29/22, and 3/23/22 revealed the facility received non-harm level citations for infection prevention and control. The facility's Plan Of Correction (POC) for Recertification and Complaint Survey dated 4/11/24, revealed correction date of 5/2/24 for infection prevention and control revealed documentation present at the end of the CMS-2567 form included the following: The Facility reasonably ensures that infection control procedures are followed. This includes the proper usage of gloves for patients during perineal cares to prevent cross contamination. 1. Residents have been receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and policy review, the facility failed to ensure residents' dignity demonstrated by lack of dressing assistance prior to a meal in the main dining room and disregard to privacy for 2 of 6 residents reviewed for dignity (Residents #84, #89). The facility reported a census of 94 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #89 dated 2/11/254 documented diagnosis included non-traumatic spinal cord dysfunction and paraplegia. The MDS revealed the resident had required substantial or maximal assistance with upper and lower body dressing. The Brief Interview for Mental Status (BIMS) exam scored 15 out of 15 which indicated intact cognition. The Care Plan focus initiated 1/23/25 for Resident #89 documented, self-care deficit as evidenced by requiring assistance with activities of daily living included dressing. Intervention under category of dressing and undressing, directed one-person assistance. The mobility category documented, does not ambulate, utilizes wheelchair that staff propels. An observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, resident interview, and staff interview, the facility failed to provide rehabilitative services as ordered for 1 of 24 residents reviewed (Resident #84). The facility reported a census of 94. Findings include: The Quarterly MDS for Resident #84, dated 01/28/2025, documented his brief interview for mental status (BIMS) score as 15, indicating intact cognition. It documented the following diagnoses: Heart failure, Hypertension, renal insufficiency, Cerebrovascular Event (Stroke), Seizure disorder, Malnutrition, Acute respiratory failure, muscle weakness, and difficulty in walking. It further documented the resident was dependent upon staff for transferring, ambulation, and personal cares. The Care Plan for Resident #84, last revised 02/03/2025, documented PT/OT would evaluate and treat as ordered. It did not document a restorative plan. Speech Therapy (ST) Plan of Treatment with start of care date 1/29/25 documented Summary of Daily Skilled Services as follows; Physician's order received. Resident would benefit from further ST services in order to maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, interviews and facility policy the facility failed to provide appropriate intervention with urinary catheter to minimize or prevent complications from the reoccurring urinary tract infections for 1 of 3 residents reviewed for urinary conditions (Residents #195). The facility reported a census of 94 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] for Resident #195 relayed resident had an indwelling catheter. Diagnoses included benign prostatic hyperplasia (enlarged prostate), renal insufficiency, septicemia and sepsis unspecified organism. The Care Plan for Resident #195 initiated 2/19/25 documented Resident #195 had the potential for infection related to a history of sepsis, pneumonia, and catheter. Resident #195 has a supra pubic catheter, Goal to be managed appropriately and not exhibit signs of infection. Intervention included to provided catheter care as per the facility policy. In an interview on 2/24/25 12:15 PM with Resident #195…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and facility contract the facility failed to effectively coordinate medication management with hospice services to assist with symptom management in relation to resident and Power of Attorney (POA) wishes for 1 of 1 residents reviewed for Hospice (Resident #73). The facility reported a census of 94. Findings include: The Significant Change Minimum Data Set (MDS) assessment, dated 1/14/25, revealed Resident #73 with a Brief Interview for Mental Status score of 14, which indicated intact cognition. Diagnoses include anxiety, depression, encephalopathy (disease in which brain function is affected by a medical condition), history of bariatric surgery, malnutrition, and Non-Alzheimer's dementia. The MDS noted a life expectancy of less than six months with Hospice Care initiated. High risk medications listed on the MDS include antipsychotics, antianxiety, antidepressants, anticonvulsant, diuretic, and opioids. The Care Plan, last review completed 1/20/25, listed Resident #73 as independent with bed mobility, eating, dressing, and mobility. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview, and policy review, the facility failed to utilize Enhanced Barrier Precautions (EBP's) and infection control practices for 1 of 4 residents sampled on EBP's (Resident #19). The facility also failed to ensure staff followed infection control practices to protect against cross contamination and potential spread of infection for a resident on droplet precautions for 1 of 4 residents on droplet/contact precautions. The facility reported a census of 94 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had diagnoses diabetes, pneumonia and a Stage 3 pressure ulcer on the left heel. The MDS indicated the resident required substantial to maximum assistance for transfers. The Care Plan revised 12/31/24 revealed the resident had impaired skin integrity related to a Stage 3 pressure ulcer to the left heel and required EBP's. The resident also required assistance with Activities of Daily Living (ADL's). The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, staff interview, resident interview, Resident Council Minutes and facility policy review, the facility failed to properly provide perineal cares for random residents and failed to provide baths/showers to residents according to their individual desires and/or needs. (Resident #2) The facility identified a census of 87 residents. Findings include: 1. During an interview 7.31.24 at 9:50 a.m. Staff F, Certified Nursing Assistant (CNA) confirmed there had been times she found residents in bed with their disposable undergarments wet all the way through their bedding completely soiled with sheets that showed signs of dried urine as noted by a dried dark circle around the wet urine which signified the resident had not been changed for a lengthy period of time. During an interview 8.1.24 at 10:43 a.m. Staff M, CNA/Shower aide confirmed she had not been able to shower residents according to their individual schedules due to staffing issues and that many residents complained however she had been unable to give specific names. The staff member also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, photos and facility policy review the facility failed to maintain a locked treatment cart on two (2) separate occasions. The facility identified a census of 87 residents: Findings include: An observation 7.30.24 at 4:46 p.m. revealed an unlocked and unattended treatment cart located along the wall outside of room N6. An observation 8.1.24 at 2:32 p.m. revealed an unlocked and unattended treatment cart located along the wall just outside of room A46. The facility had identified 8 residents who wandered. According to an email 8.6.24 at 3:56 p.m. the Administrator confirmed she expected staff to have locked medication and treatment carts when unattended. A Security of a Medication Cart policy not dated indicated the medication carts should have been secured during medication passes. The Policy Interpretation and Implementation included the following: a. The nurse must have secured the medication cart during the medication pass for prevention of an unauthorized entry. b. When it had not been possible to park the medication cart in the doorway, the cart should have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, resident interview and staff interview the facility failed to provide restorative exercises according to the resident's individual plan of care for 2 of 3 residents reviewed. (Resident #2 and #5) The facility identified a census of 87 residents. Findings include: 1. According to an email 8.6.24 at 9:54 a.m. the Administrator indicated residents on the restorative program should have received their exercises 3-6 times per week. 2. A Significant Change Minimum Data Set (MDS) assessment form dated 5.30.24 indicated Resident # 2 had diagnosis that included a Neurogenic Bladder, Urinary Tract Infections (UTI) and Arthritis. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact) and required staff assistance with most activities of daily living (ADL's). The MDS documented that the resident had three days of occupational and physical therapy with the start date of 5/15/24 to end date 5/28/24. Review of restorative records dated 7.4.24 through 8.1.24 for Resident #2 directed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, staff interview and facility policy review the facility failed to ensure staff maintained a safe and secure environment for 1 of 3 residents at an elopement risk. (Resident #4) The facility identified a census of 87 residents. Findings include: A Quarterly Minimum Data Set (MDS) assessment form dated 6.11.24 indicated Resident #4 had diagnosis that included Hypertension (HTN), Non-Alzheimer's Dementia, Depression and repeated falls. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (moderately impaired cognitive skills) and independent with ambulation. A Care Plan addressed the following Problem areas and Interventions as dated: a. A self-care deficit as evidenced by required staff assistance with activities of daily living (ADL's), impaired balance during transitions and required assistance for ambulation. (revised 3.8.24). 1. One (1) staff assistance with transfers and mobility. (revised 3.8.24) b. At risk for falls related to (r/t) impaired balance, poor safety awareness,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility policy review, and facility maintenance records, the facility failed to maintain the combination walk-in freezer and refrigerator in a clean and satisfactory condition. The facility reported a census of 89. Findings include: Observation on 04/08/24 at 1:15 PM revealed frost in the freezer had recently melted, formed an icicle, and dripped on an open box of chicken. The icicle that hung in the corner was approximately six inches in length at the time of the initial observation. On 04/11/24 at 09:02 AM Staff R, Dietary Supervisor stated they have been aware of the frost and drip issue for the duration of their employment, about one year. They noted it is the responsibility of kitchen staff and the dietary supervisors to report issues with the freezer to the maintenance supervisor. They reported staff have been instructed not to place items under the areas of the freezer where the dripping occurs. On 04/11/24 at 09:05 AM Staff P, Maintenance Supervisor reported he was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, resident statements, staff interview and facility policy review, the facility failed to contain odors, wipe soiled surfaces and clear cluttered hallways to promote a homelike environment. The facility reported a census of 89 residents. Findings include: Observation on 04/10/24 at 08:55 AM revealed a strong, very pungent ammonia / urine odor from the dirty linens present in A Hallway. Odor first noted outside of room A40. A fan on the wall near the ceiling blew down on the dirty linen and the trash containers which were covered. The urine odor continued to the next room outside of room A42 which also contained a barrel labeled trash only - 33 gallon bin. The strong urine smell continued past room A44 and A46 where the smell dissipated near the nurses station. The linen bin contained a half full clear trash bag lining which was visible as the zipper not zipped up on the outside cloth liner. Soiled bed incontinence pads could be seen within the linen bin. Observation on 04/10/24 at 09:06 AM revealed the presence of a strong, very pungent ammonia smell outside of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, family interview, staff interview, and the facility policy review, the facility failed to promptly notify resident representative when there was a room change with resident health changes for 1 of 1 residents (Residents #242) reviewed. The facility reported a census of 89 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #242 dated 4/05/2024 documented an admission date of 4/01/2024. The MDS documented the resident had a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The Clinical Record Review of Resident #242 indicated having a family member, daughter, involved in discussions about health status and changes from the date of the admission. During an interview on 4/11/24 at 12:30 PM with Resident #242 daughter, it was revealed that the facility did not notify her of the room change. During an interview on 4/11/24 at 2:30 PM with the Administrator, she confirmed that the facility failed to notify Resident #242 representative prior to a room change. Review of a facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, the facility failed notify the long term care ombudsman for resident transfers to an acute care hospital for 1 of 4 residents reviewed for rehospitalization (Resident #44). Findings include: The census line of the Electronic Health Record of Resident #44 reflected the resident was on an unpaid hospital leave from 1/3/24 through 1/10/24. The General Progress Note dated 1/3/24 at 5:30 pm reflected the resident was making suicidal statements in a conversation with the Social Worker. The progress note documented the social worker reported this to the Director of Nursing and was instructed to call 911 and the resident was sent to the hospital at approximately 5:30 pm. The admission Assessment note dated 1/10/24 reflected the resident returned to the facility on that date. The Notice of Transfer Form to Long Term Care Ombudsman with an email date of 2/5/24 failed to document resident #44 to be included on the list of residents reported to the Ombudsman to have transferred from the facility in January 2024. On 4/10/24 at 1:53 pm, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and staff interview, the facility failed to accurately code resident MDS (Minimum Data Set) assessments to reflect accurate resident conditions for 2 of 18 sampled residents (Resident #2, #47). Resident #2 inaccurately coded as having no PASRR (Preadmission Screening and Resident Review) level II evaluation and Resident #47 inaccurately coded for the use of bed rail restraint. The facility reported a census of 89 residents. Findings include: 1. The Annual MDS assessment dated [DATE] for Resident #2 documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS recorded no response under Level II PASRR conditions: Serious Mental Illness, Intellectual Disability, or Other related conditions. The MDS documented active diagnoses that included psychiatric / mood disorders of: anxiety, depression, bipolar depression, psychotic disorder, and schizophrenia. The MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review, the facility failed to update and revise the Care Plan to reflect therapy recommendations of resident restorative activities program for three of three sampled residents in order to maintain a functional range of motion and activities of daily living (Residents #19, #28, and #44). The facility reported a census of 89 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had diagnoses of congestive heart failure (CHF), chronic kidney disease, and cancer. The MDS revealed Resident #19 independent with bed mobility, toileting and transfers. The MDS indicated the resident not steady but able to stabilize without staff assistance when she moved from a seated to standing position and when transferred between the bed and chair or the wheelchair. The MDS recorded the resident's range of motion (ROM) not impaired. The resident had Occupational Therapy (OT) 12/20/22 to 1/10/23, and Physical Therapy (PT)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical records review, staff interviews and policy review, the facility failed to properly transcribe and implement provider orders for 1 (Resident #18) of 7 residents reviewed for medication orders. The facility reported a census of 89 residents. Findings include: The MDS of Resident #18 dated 2/21/24 identified a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS revealed the resident required substantial assistance for bed mobility. The MDS reflected the resident experienced frequent urinary incontinence. The MDS recorded the presence of one Stage 3 pressure ulcer with no pressure ulcers present upon the resident's admission to the facility, and one diabetic foot ulcer. The MDS failed to reveal the presence of of Moisture Associated Skin Damage. The Care Plan of Resident #18 revealed a focus area of self care deficit with a revision date of 10/11/23. The Care Plan noted the resident to have a history of refusing cares or assistance with cares. The Care Plan directed staff the resident required 1 person assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and policy review, the facility failed to provide restorative activities for three of three sampled residents in order to maintain a functional range of motion and prevent a decline in activities of daily living (Residents #19, #28, and #44). The facility reported a census of 89 residents. Findings include: 1. The Significant Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had diagnoses of congestive heart failure (CHF), chronic kidney disease, and cancer. The MDS revealed Resident #19 independent with bed mobility, toileting and transfers. The MDS indicated the resident not steady but able to stabilize without staff assistance when she moved from a seated to standing position and when transferred between the bed and chair or the wheelchair. The MDS recorded the resident's range of motion (ROM) not impaired. The resident had occupational therapy (OT) 12/20/22 to 1/10/23, and physical therapy (PT) 1/2/23 to 1/11/23, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident council meeting, clinical record review, observation, and resident and staff interviews, the facility failed to provide sufficient and competent staff to meet resident needs with bathroom cares and answering call lights timely for 1 of 10 group resident interview and 2 of 18 sampled residents (Resident #15, #13, #4, #31). The facility reported a census of 89 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had diagnoses of Lewy Body dementia, diabetes, and pruritis (itching). The MDS recorded the resident had a Brief Interview for Mental Status (BIMS) score of 4,which indicated severely impaired cognition. The MDS documented the resident required substantial to maximal assistance for toileting, dressing, and personal hygiene, and had incontinence. The Care Plan revised 3/6/24 revealed the resident had incontinence and at risk for impaired skin integrity and had rashes/irritations. The staff directives included provide peri-care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, and staff interview, the facility failed to ensure a resident who desired to receive routine dental care for a cleaning and to assess for possible oral cavities received arrangement of services for 1 of 1 residents reviewed for dental services (Resident #15). The facility reported a census of 89 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 identified a BIMS (Brief Interview for Mental Status) score of 15 which indicated intact cognition. The Significant Change MDS dated [DATE] recorded under the dental section the resident with obvious or likely cavity or broken natural teeth. The Progress Notes dated 9/1/2023 and 12/26/2023 indicated the resident requested dental services with no follow-up documentation contained in progress notes. On initial interview 04/08/24 at 4:10 PM Resident #15 stated she had been on the list to go to the dentist for months. On 04/09/24 at 03:09 PM staff in charge of dental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and facility policy review, facility staff failed to follow infection control practices in order to prevent and control the onset and spread of infection within the facility by not removing soiled gloves and performing hand hygiene for two of two nursing units observed. The facility also failed to disinfect resident care devices when soiled with urine and failed to ensure staff utilized infection control techniques in order to prevent cross contamination for 3 of 4 residents observed during incontinence cares (Resident #2, #31, and #47). The facility reported a census of 89 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had diagnoses of Lewy Body dementia, diabetes, and pruritis (itching). The MDS recorded the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The MDS documented the resident required substantial to maximal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on CDC (Center for Disease Control) recommendations, clinical record review, and staff interview, the facility failed to provide education and administration of pneumococcal immunization for 28 residents identified by the facility eligible to be offered and 2 of 5 residents reviewed for pneumonia vaccine (Resident #18, #47). The facility reported a census of 89 residents. Findings include: The CDC website, https://www.cdc.gov/vaccines/vpd/pneumo/, published 9/21/23 recorded the CDC recommended PCV15 or PCV20 for adults who never received a PCV and are ages 65 years or older. For ages 19 through [AGE] years old with certain risk conditions, if PCV15 was used, it should be followed by a dose of PPSV23. The CDC recommended adults who received an earlier PCV (PCV7 or PCV13) should talk with a vaccine provider. The provider can explain available options to complete the pneumococcal vaccine series. Adults 65 years or older have the option to get PCV20 if they have already received PCV13 (but not PCV15 or PCV20)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and pictures the facility failed to maintain a clean, safe and homelike environment. The facility identified a census of 94 residents. Findings include: 1. An observation and photo taken 2.7.24 at 9:12 a.m. revealed two (2) holes on the wall beside the bed of Resident #1 repaired with Spackle however not sanded and/or painted. An observation and photo taken 2.7.24 at 9:13 a.m. revealed the linoleum/laminate flooring in the Resident's room separated and not sanitizable. 2. An observation and photo taken 2.8.24 at 9:13 a.m. revealed 2 holes on the wall beside the bed of Resident #2 repaired with Spackle however not sanded and/or painted. 3. An observation and photo taken 2.8.24 at 9:13 a.m. revealed 2 holes on the wall beside the bed of Resident #3 repaired with Spackle however not sanded and/or painted. An observation 2.13.24 at 12:50 p.m. revealed the same observation as documented above. 4. An observation 2.1.24 at 4:30 p.m. revealed a brown substance with the appearance of stool on the wall beside the bed of Resident #11. A photo taken 2.1.24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review and facility policy review, the facility failed to properly provide perineal cares for 2 of 3 residents reviewed (Resident #2 and Resident #11) The facility identified a census of 94 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) assessment form dated 11.16.23 indicated Resident #2 had diagnosis that included Cerebral Palsy, Autistic Disorder, Entercolitis due to Clostridium difficile (C-Diff) , Seizures and Intellectual Disabilities. The assessment identified the Resident with short and long term memory deficits, severally impaired cognitive skills, as always incontinent of his bowels and bladder and as dependent on staff with toileting hygiene. A Care Plan identified the following Problem and Interventions as dated: a. Self-care deficit as evidenced by required assistance with activities of daily living (ADL's), impaired balance during transitions required assistance and incontinence. (revised 8.30.23) 1. The resident had been unable to use the toilet, bed pan or bed side commode. Assistance required with check and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident interview, staff interview, Resident Council Minutes and facility policy review the facility failed to answer resident call lights within the allotted professional standards of 15 minutes for 2 of 4 residents reviewed. (Resident #3 and Resident #6) The facility identified a census of 94 residents. Findings include: An observation 2.11.24 at 4:28 p.m. revealed the call light on for room B 43 which staff answered at 4:50 p.m. During an interview 2.8.24 at 9:15 a.m. the Resident #3 indicated she waited a long, long time for call lights but there had been nothing that could have been done because any anger would have not solved the problem. During an interview 2.11.24 at 4:10 p.m. Resident #3 indicated on 2.10.24 during the afternoon she timed her call light on for 3 hours as she used the clock on her wall. The Resident stated she finally called her daughter in law and had her call the facility and tell them she required assistance. During an interview 2.1.24 at 4:01 p.m. Resident #6 indicated when she went to the bathroom and placed her call light on for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, record and facility policy review, the facility failed to reconcile narcotic/controlled substance counts at the beginning and ending of every shift for four of four medications carts. The facility census was 94 residents. Findings include: 1. Record Review of the Scheduled 2 Narcotic Shift Count for February 2024, revealed that the following dates lacked signature that acknowledged the controlled drug count was correct on: *South Hall Cart on 2/2/24 at the beginning/end of the 2:00 p.m., to 10:00 p.m. shift, and on 2/6/24 the beginning of the 2:00 p.m. shift. *West Hall Cart on 2/3/24 at the beginning/end of the 2:00 p.m. to 10:00 p.m. shift. *AB Hall Cart on 2/6/24 at the beginning/end of the 2:00 p.m. to 10:00 p.m., shift. 2. Record Review of the Scheduled 2 Narcotic Shift Count for January 2024, revealed that the following dates lacked signatures that acknowledged the controlled drug count was correct on: *AB Hall Cart on 1/17/24, 1/23/24, 1/25/24, at the beginning/end of the 2:00 p.m., to 10:00 p.m. shift. *BC Hall Cart on 1/3/24, at the beginning/end…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and facility policy review, the facility staff failed to remove soiled gloves during personal cares for 2 of 3 residents reviewed. (Resident #2 and Resident #11) The facility identified a census of 94 residents. Findings include: 1. An observation 2.7.24 at 9:30 a.m. revealed Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA DONN (put on) proper personal protective equipment (PPE) which included gloves since Resident #2 had been diagnosed with Clostridioides Difficile (C-Diff), an infectious disease of the colon) and had been placed on contact precautions. The Staff C confirmed the resident as incontinent of urine. With gloved hands Staff C pulled down resident ' s brief, cleansed the resident anteriorly, positioned the resident on his left side while she touched his person, bedding and clothing with the same gloved hands and then cleansed the resident posteriorly. With the same gloved hands Staff C assisted Staff B as they pulled up the resident's clean brief. Staff B stepped away from the area, removed gown and gloves, washed hands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and review of Resident Rights the facility staff failed to treat 2 of 3 residents with dignity and respect while providing resident cares. (Resident #11 and Resident #15) The facility identified a census of 94 residents. Findings include: 1. An observation 2.1.24 at 4:48 p.m. revealed Staff H, CNA and Staff I, CNA as they opened the room door of Resident #11 without having knocked and/or announce themselves. They stood at the resident's bedside and looked at the resident who layed in bed with her eyes closed. Staff I left the room as Staff H remained at the Resident's bedside . Staff I returned, left the room door ajar approximately 4 centimeters (cm) as other residents and staff walked past. The staff members proceeded to provide perineal cares which exposed the resident to the staff and residents who walked past her room. 2. An observation 2.2.24 at 11:07 a.m. revealed Resident #15 disrobed from the top up as she sat in her recliner in her room right inside the door visible to all residents, families and staff who walked by and with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, staff interview and facility policy review, the facility failed to properly provide care and treatment to a pressure ulcer for 1 of 3 residents reviewed. (Resident #2) The facility identified a census of 94 residents. Findings include: A Quarterly Minimum Data Set (MDS) assessment form dated 11.16.23 indicated Resident #2 had diagnosis that included Cerebral Palsy, Autistic Disorder, Entercolitis due to Clostridium Difficile (C-Diff) , Seizures and Intellectual Disabilities. The assessment identified the Resident with short and long term memory deficits, severally impaired cognitive skills. The MDS documented the Resident as always incontinent of his bowels and bladder, dependent on staff with toileting hygiene, and at risk for pressure ulcers. A Care Plan identified Interventions/Tasks to have provided treatments as ordered. (dated 6.8.23) A Treatment Administration Record (TAR) form directed the facility staff to have cleansed the resident's wound to his coccyx area with a cleanser of choice followed by an application of a foam boarder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and resident interview, the facility failed to follow physician's orders for 2 of 3 residents reviewed, (Resident #6 and Resident #7 ) The facility identified a census of 90 residents. Findings include: 1. A Medication Administration Record (MAR) form for Resident #6 dated 11/1/23 thru 11/30/23 indicated the resident received the following insulin orders from the physician to have been administered as indicated: a. Lispro (short acting insulin) sliding scale insulin for blood sugars between 201-250 administration of 4 units at 8 a.m. for diabetes mellitus (DM) b. Levemir (long acting insulin) Subcutaneous Solution inject 100 units subcutaneous every morning and at bedtime at 8 a.m. and 8 p.m. for DM. During an observation on 11/16/23 at 8:54 a.m. Staff A, Registered Nurse (RN) administered the medications for Resident #6 as follows: a. Mucinix DM one (1) two (2) times a day (BID). The staff member placed the Mucinix directly into her ungloved and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident interview, staff interview, resident council minutes and facility policy review the facility failed to answer resident call lights within the allotted professional standards of 15 minutes, (Resident #5 and #6) The facility identified a census of 90 residents. Findings include: During an interview on 11/16/23 at 12:41 p.m. Resident #5 confirmed she timed her call light as on for up to an hour on the 2 p.m.- 10 p.m. shift as she used the clock on the wall beside her bed which caused frustration. The resident indicated the staff thought it took a 1/2 an hour for her hour of sleep (HS) cares so they failed to answer her call light which she felt had not been true. During an interview on 11/16/23 at 1:04 p.m. Resident #6 described call lights as terrible at the facility and staff walked around like snails. The resident timed her call light on as long as one (1) hour as she used her her cell phone or television. The resident described the call lights as worse on the 2 p.m. till 10 p.m. shift which pissed her off. There had been times she called the nurse's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, resident interview, staff interview and Resident Council minutes the facility staff failed to treat 2 of 4 residents with dignity and respect during the showering process, (Resident #4 and #5) and failed to provide proper discussions during resident cares. The facility identified a census of 90 residents. Findings include: A Minimum Data Set (MDS) form dated 9/27/23 indicated Resident #4 had diagnosis that included anemia, renal insufficiency, diabetes mellitus (DM) and non-alzheimer's dementia . The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 (severely impaired cognitive skills) and bathing had not occurred in the look back period for the assessment. (7 days) A Care Plan with a Problem revised 9/29/23 indicated the resident with a self-care deficit as evidenced by required assistance with activities of daily living (ADL's). The interventions included the following: a. Bathing/showering: One person assistance. Encouraged bathing two times a week. (revised 4/28/23) An observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, resident interview and staff interview, the facility failed to properly clean and maintain the highest functional capability for an oxygen concentrator for one resident reviewed, (Resident #6) The facility identified a census of 90 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 10/24/23 indicated Resident #6 had diagnosis that included cancer, anemia, atrial fibrillation, coronary artery disease, heart failure and respiratory failure. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), with shortness of breath (SOB) when she laid flat and on oxygen (O2) therapy. A Care Plan with a Problem revised 8/10/23 documented the resident as on continuous oxygen and as at risk for alteration in levels O2 due to chronic obstructive pulmonary disease (COPD), history of smoking and chronic respiratory failure. The approaches included the following: a. Oxygen via nasal canula (NC) as ordered. (initiated 7/25/23) A Medication Administration Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review and facility policy review the facility failed to provide the necessary assessments for 1 of 3 residents reviewed following a fall, (Resident #1) The facility identified a census of 90 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 10/8/23 indicated Resident #1 had diagnosis that included aphasia, cerebrovascular accident (CVA) and hemiplegia. The MDS indicated the resident as rarely/never made self understood and/or understood others, short term and long term memory deficits and severely impaired cognitive skills. The assessment indicated the resident suffered from an impairment of both sides of his upper and lower extremities and as dependent on staff with activities of daily living (ADL's). A Care Plan with a Problem area initiated 6/15/23 and revised 11/16/23 indicated the resident at risk for falls related to a diagnosis of hemiplegia which affected his right dominant side. A Progress Notes entry dated 11/14/23 at 10:45 p.m. included the following documentation: a. 11/14/23 at 6:30 p.m. the resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.