Allison Care Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from sexual abuse for one (#1) of four residents reviewed for abuse out of five sample residents. Specifically, the facility failed to protect Resident #1 from sexual abuse by a facility employee, housekeeper (HK) #1.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#1 and #3) of four residents were free from abuse out of four sample residents. Resident #2 was admitted on [DATE] with diagnoses of dementia, transient ischemic attack (TIA- a temporary blockage of blood flow to the brain), hypertension, repeated falls and dysphagia. Resident #1 was admitted on [DATE] with diagnoses of hemiparesis (weakness on one side of the body) affecting left side , cerebral infarction (disrupted blood flow to the brain), dysphagia (difficulty swallowing), dementia (loss of cognitive function), systolic heart failure (ineffective blood pumping), type two diabetes (abnormal glucose control), displaced fracture of the wrist and hypertension (high blood pressure). Resident #2 and Resident #1 were roommates who resided on the secured unit. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#279, #30 and #40) of six residents reviewed for accidents out of 39 sample residents remained free from accidents. RESIDENT #279 Resident #279, was admitted on [DATE] with diagnoses of hemiplegia (weakness on one side) after an intracerebral hemorrhage (stroke) and dementia with behaviors. The resident was identified to be at very high risk for falling. On 2/12/25 Resident #279 experienced a fall shortly after admission and the facility implemented a fall care plan with interventions which included ensuring the resident's call light was in reach and encouraging the resident to use the call light. However, the resident had severe cognitive impairments. Resident #279 sustained witnessed falls on 2/14/25 and 2/15/25. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#44, #59 and #13) of six residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being out of 39 sample residents. Resident #44 was admitted to the facility for long term care on 9/2/22. It was identified that Resident #44 was at risk for weight loss and nutritional decline due to Alzheimer's disease, previous history of weight loss and hyperthyroidism (increased metabolism due to an overactive thyroid gland). On 10/8/24, Resident #44 weighed 146.5 pounds (lbs). On 12/5/24, Resident #44 weighed 136 lbs, which indicated the resident had lost 10.5 lbs in two months. In December 2024 the facility increased the resident's Med Pass (oral nutritional supplement). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure the staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP); -Ensure resident rooms were cleaned in a sanitary manner; and, -Ensure medications were handled in a sanitary manner.

Inspectors wroteBased on record review and interviews, the facility failed to prevent physical abuse for one (#274) of three residents reviewed for abuse out of 39 sample residents. Specifically, the facility failed to protect Resident #274 from physical abuse by Resident #276.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for one (#37) of three residents reviewed for services to maintain highest practicable quality of life out of 39 sample residents. Specifically, the facility failed to ensure Resident #37 consistently received assistance to maintain oral hygiene.

Inspectors wroteBased on observations, record review and interviews, the facility failed to use a person-centered approach when determining the use of a grab bar/bed rail for one (#37) of one resident reviewed for grab bars/bed rails out of 39 sample residents. Specifically, for Resident #37, the facility failed to: -Identify alternatives to using grab bars/bed rails prior to installing grab bars/bed rails; and, -Conduct routine assessments and maintenance of the resident's grab bar/bed rail to evaluate the continued safety and/or the continued need for the grab bar/bed rail.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#52) of three residents out of 29 sample residents Specifically, the facility failed to offer and provide personalized activity programs for Resident #52 when she had a change in activity participation.

Inspectors wroteBased on record review and interviews the facility failed to ensure each nurse aide has no less than twelve hours of in-service education per year based on their facility policy and facility assessment for four out of 32 certified nurse aides (CNAs). Specifically, the facility failed to ensure CNAs (#10, #11, #13, and #14) that had worked in the facility for one year or longer had the appropriate hours of in-service training with no less than 12 hours of annual in-service hours. Cross-referenced to F943 failure to provide all staff annual abuse identification and prevention and dementia management. Cross-referenced to F609 failure to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately.

Inspectors wroteBased on observations, record review and interview, the facility failed to implement an effective infection prevention and control program, based on the facility assessment, to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of potential communicable diseases and infections. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate housekeeping procedures and used proper cleaning and disinfecting products; -Ensure adequate hand hygiene for housekeeping staff.

Inspectors wroteBased on record review and interview, the facility failed to provide training to their staff that at a minimum educates staff on: Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically the facility failed to: -Provide annual abuse identification and prevention training for five (5) out of Six (6) employees; and -Provide annual dementia management training for four (4) out of six (6) employees. Cross-referenced to F730 Failure to ensure certified nursing aides (CNA) that had worked in the facility for one year or longer had the appropriate hours of in-service training. [...]

Inspectors wroteBased on observation record review and interviews, the facility failed to ensure that all resident were free from abuse, neglect, and exploitation, for three residents (#52, #78, and #45) of eight out of 39 sample residents. Specifically, the facility failed to prevent abuse from occurring and failed to implement all possible interventions to protect the resident(s) from further harm for physical abuse in altercations between Residents #52 and #78 and Residents #78 and #45.

Inspectors wroteBased observation record review and interviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, for two residents (#11 and #46) of five, out of 39 total sampled residents. Specifically, the facility failed to: -Report an injury of unknown source to the State agency for Resident #11; and, -Report an allegation of neglect, to the State agency, in a timely manner for Resident #46.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an effective discharge planning process to communicate necessary information to the Resident, continuing care providers and other authorized persons at the time of an anticipated discharge for one (#84) of one out of 39 sample residents reviewed for a closed record discharge. (Cross-reference F661 Discharge Summary The discharge summary was to include the Resident's reason for discharge, primary care physician contact information, follow up appointments, community resources, medical equipment provider contact information, and therapy information.) Specifically, the facility failed to ensure: [...]

Inspectors wroteBased on record review, observation and interviews, the facility failed to provide a completed discharge summary for one (#84) of one out of 39 sample residents reviewed for a closed record discharge. (Cross reference F660 Discharge planning to communicate necessary information to the Resident, continuing care providers and other authorized persons at the time of an anticipated discharge) Specifically, the facility failed to ensure Resident #84 was provided with an appropriate discharge summary of her stay at the facility. The discharge summary was to include the reason for discharge, primary care physician contact information, follow up appointments, community resources, medical equipment provider contact information, and therapy information.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary assistance with activities of daily living (ADLs) for two (#46 and #58) of three residents reviewed for ADLs out of 39 sample residents. Specifically, the facility failed to ensure: -Resident #46, dependent on staff with toileting, was provided timely incontinent care; and, -Resident #58, dependent on staff with personal hygiene, nails were trimmed and cleaned.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices; for two (#11 and #23) of two residents, out of 39 total sample residents. Specifically, the facility failed to follow a physician's orders to: -Notify the prescribing physician when Resident #11s blood glucose level tested below a specific level; and, -Follow blood pressure parameters for Resident #23.

Inspectors wroteIII. Resident #49 A. Resident status Resident #49, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician orders (CPO) diagnosis included wedge compression fracture of the thoracic vertebra, wedge compression fracture of the first and second lumbar vertebra with routine healing, non-displaced fracture of anterior wall of the right hip with routine healing, pathological fracture of the pelvis with routine healing; unspecified dementia; and weakness with difficulty in walking. The 10/16/19 minimum data set (MDS) assessment, the resident cognition was moderately impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The resident showed no physical, verbal or other behavioral expressions of aggression or harm to self or others. She did reject care four to six days a week but not daily. [...]