Allegany Health Nursing and Rehab

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's current status. This was found to be evident for one (Resident #28) out of three residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and medical record review it was determined that the facility failed to ensure an interdisciplinary care plan meeting was held to review and revise the resident's care plan after the completion of a Minimum Data Set (MDS) assessment. This was found to be evident for one (Resident #6) out of two resident's reviewed for urinary catheter use.

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure the provision of activities to meet the needs of residents with dementia. This was found to be evident for 2 (Resident #122 and #9) out of 5 residents reviewed for dementia care.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to develop a care plan to address the resident's needs related to the use of an indwelling urinary catheter and failed to ensure that a resident was assessed for the possible removal of the urinary catheter. This was found to be evident for one (Resident #6) out of two residents reviewed for indwelling urinary catheter usage.

Inspectors wroteBased on interview, and record review it was determined that the facility failed to ensure nursing staff were evaluated for competence. This was evident for 2 of 2 Registered Nurses (Staff #11, #13) employee files reviewed for skills and competency.

Inspectors wroteBased on record review and interview it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) had their performance evaluated. This was evident for 2 (Staff #14, #15) of 2 GNAs reviewed for performance evaluation.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure the accuracy and integrity of controlled substance reconciliation records. This deficient practice was identified in 1(3rd floor south cart) of 3 medication storage areas observed.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the accuracy of clinical records, specifically the electronic medication administration record (eMAR). This deficient practice was identified for 1 (Resident #15) of 3 resident medication administration observations.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to use infection prevention strategies. This was found to be evident during two out of two observation of the laundry facility; the review of the water management plan to prevent Legionella; and review of one (Resident #16) out of three residents reviewed for pressure ulcer care.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that the call system was accessible to meet resident needs. This was evident for 1 (Resident #46) of 1 residents observed for call system accessibility.

Inspectors wroteBased on record review and interview it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received the required 12 hours of annual training. This was evident for one (Staff #14) of two GNAs reviewed for annual training.

Inspectors wroteBased on reviews of a facility-reported incident, a closed medical record and all pertinent information and staff interview, it was determined that the facility staff failed to identify a newly admitted Resident who was admitted without clear physician's order for end-of-life care and failed to follow the facility policy to initiate Cardiopulmonary Resuscitation (CPR). This was evident for 1 (Resident #902) of 11 facility-reported incidents reviewed during an annual recertification survey. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of [DATE].

Inspectors wroteBased on reviews of a facility-reported incident, a closed medical record and all pertinent information, and staff interviews, it was determined the facility staff failed to provide adequate supervision and follow the resident's plan of care to: 1) prevent a fractured humerus during a transfer, and 2) to prevent a cognitively and functionally impaired resident from sliding out of bed onto the floor and receiving bilateral fractured hips. This was evident for 2 (Residents #909, #906) out of 11 facility-reported incidents resulting in harm to both residents reviewed during the survey. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 07/11/23.

Inspectors wroteBased on reviews of the facility investigation and all pertinent administrative documents, a closed clinical record, and staff interview, it was determined that the facility failed to ensure that a resident remained free of abuse. This was true for 1 (Residents #901) of 11 facility reported incidents reviewed during an annual recertification survey. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facilitie's plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 09/10/20.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure residents were free of physical restraints for one of 22 sampled residents (Resident (R) 44). R44 was observed in a geriatric chair and a wheelchair with an added lap tray which prevented R44 from standing up for staff convenience. This failure placed R44 at risk for increased anxiety, agitation, and a diminished quality of life.

Inspectors wroteBased on an anonymous complaint, reviews of closed medical records and pertinent administrative policies and records, and staff interview, it was determined that facility administrative staff failed to implement the facility's existing abuse policy and procedures when an allegation of sexual abuse was reported by 2 staff members. This was evident for 1 (Resident #911) of 6 complaints reviewed during an annual recertification survey.

Inspectors wroteBased on an anonymous complaint, reviews of closed medical records and pertinent administrative policies and records, and staff interview, it was determined that facility administrative staff failed to report an allegation of resident to resident sexual abuse to the State Survey Agency. This was evident for 1 (Resident #911) of 6 complaints reviewed during an annual recertification survey.

Inspectors wroteBased on an anonymous complaint, reviews of closed medical records and pertinent administrative policies and records, and staff interview, it was determined that facility administrative staff failed to investigate an allegation of resident to resident sexual abuse when it was reported by staff members. This was evident for 1 (Resident #911) of 6 complaints reviewed during an annual recertification survey.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to revise residents care plan to include the use of a geriatric chair and lap trays for one of 22 sampled residents (Resident (R) 44). This failure placed the resident at risk for unmet care needs, safety risks, and increased anxiety related to devices that were considered restraints.

Inspectors wroteBased on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure that Resident #28 was aware of a treatment that could be administered. This was evident for 1(#28) of 45 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure all nursing staff that has the potential to work on the third floor was in-serviced to ensure the center stairway door in shut when exiting the unit and to check the door that it closes completely and that no residents are attempting to leave behind staff. (Resident #19). This was evident for 1(# 19) of 45 residents selected for review during the annual survey process.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to ensure that proper hygienic practices were followed with the use of a nasal cannula (#125). This was evident for 1 (#125) out of the 43 residents that were part of the survey sample.