Allied Services Center City Skilled Nursing

Inspectors wroteBased on review of select facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents had reasonable and safe access to operate their over-the-bed lighting for four residents out of 21 residents reviewed (Residents 32, 50, 9, and 41).

Inspectors wroteBased on a review of clinical records, select facility policy, and resident and staff interviews, it was determined that the facility failed to timely identify weight loss, failed to ensure weekly weights were obtained as required by policy for prompt intervention for two of 21 sampled residents (Residents 15 and 22), and failed to implement individualized nutritional support measures based on a resident's stated preferences to maintain or improve nutritional parameters for one resident (Resident 8) out of three sampled residents for weight loss.

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and staff interviews, it was determined that the facility failed to provide person-centered care as prescribed to meet the current clinical needs and failed to follow physician orders for the management of a Peripherally Inserted Central Catheter (PICC) line for three of 21 sampled residents (Residents 12, 75, and 76).

Inspectors wroteBased on observation, review of select facility policy, and staff interviews, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage for medications on one of three nursing units (Nursing Unit 3).

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to consistently implement measures planned to prevent the development of pressure sores for one resident out of 21 residents sampled (Resident 76).

Inspectors wroteBased on clinical record review, review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility to the extent possible for one resident out of 21 residents sampled (Resident 2).

Inspectors wroteBased on a review of clinical records, select facility policy, controlled substance records, and staff and resident interviews, it was determined that the facility failed to follow physician orders, complete timely pain assessments, implement measures to reduce or alleviate pain, reassess the effectiveness of pain interventions within a reasonable time frame, and accurately document these activities in the clinical record for three of 21 sampled residents (Residents 15, 45, and 23).

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to implement enhanced barrier infection control procedures for three residents out of the 21 residents sampled (Residents 28, 33, and 56) and failed to properly store resident hygiene and personal products in two out of three resident shower rooms (3rd and 4th floor shower rooms).

Inspectors wroteBased on a review of clinical records, the Resident Assessment Instrument, and staff interview, it was determined the facility failed to ensure that Minimum Data Set Assessments accurately reflected the status of three residents out of 21 sampled (Residents 34, 8, and 31).

Inspectors wroteBased on observations, a review of clinical records, and resident and staff interviews, it was determined the facility failed to provide person-centered care by failing to follow physician's orders for the consistent application of a prescribed therapeutic measure, compression stockings, for one resident of 21 sampled (Resident 22).

Inspectors wroteBased on a review of clinical records, facility-provided manufacturers' medication information, and staff interviews, it was determined the facility failed to demonstrate the physician timely acted upon irregularities identified by pharmacy services during drug regimen reviews for one resident out of the five sampled (Resident 56).

Inspectors wroteBased on observation, a review of clinical records, and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three of the five residents attending a group meeting (Residents 1, 7, and 23) and two out of the 17 residents sampled (Residents 13 and 23).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean environment on one of two nursing units (Nursing Unit 2).

Inspectors wroteBased on a review of clinical records and a staff interview, it was determined that the facility failed to ensure necessary resident information was communicated to the receiving health care provider for four transferred residents out of five sampled residents (Residents 11, 13, 36, and 45).

Inspectors wroteBased on review of select facility policy and controlled drug records, observation and staff interview, it was determined that the facility failed to implement procedures to promote accurate medication administration, and records accounting for controlled drugs for one of three residents sampled (Resident 57), and reconciliation of controlled drugs on three of three medication carts (4th, 2 east, and 2 west).

Inspectors wroteBased on observation, review of clinical records and select incident reports and resident and staff interviews it was determined that the facility failed to timely and effectively monitor a resident's use of a therapeutic device to preserve skin integrity and prevent pressure sore development, which resulted in the development of an avoidable pressure sore by one resident out of three reviewed (Resident 53).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services to maintain the mobility and functional abilities of one of the 17 residents sampled (Resident 15).

Inspectors wroteBased on a review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to ensure each resident room is designed and equipped to assure full visual privacy for two out of the 17 residents sampled (Resident 15; Resident room [ROOM NUMBER], Resident 13 room [ROOM NUMBER]).

Inspectors wroteBased on record review and interview, it was determined that the facility failed to submit accurate staffing information in the Payroll-Based Journal (PBJ) system for two of the four quarters reviewed (October 1, 2023, through December 31, 2023, and July 1, 2023, through September 30, 2023).