Altoona Nursing and Rehabilitation Center

Inspectors wroteBased on observation, clinical record review, hospital record review, staff and resident interview, mechanical lift user manual, and facility policy review, the facility failed to ensure the safety of residents during a full body mechanical lift transfer for 1 of 3 residents reviewed for safe transfers (Res #2). This resulted in harm to Resident #2 when he fell from the mechanical lift sling during a transfer, resulting in a hip fracture and leg wound. The facility reported a census of 98 residents. Following this event, the facility implemented the following corrective actions:Conducted an immediate internal investigation and Root Cause Analysis (RCA) of the fall, including a simulated transfer to identify contributing factors. Inspected the mechanical lift and sling involved in the incident, as well as all other lifts and slings within the facility, to ensure equipment integrity. [...]

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, the facility failed to follow medical provider orders for 2 of 3 residents (Res #1, Res #4) reviewed for wound management. The facility reported a census of 98 residents.

Inspectors wroteBased on clinical record review, staff and family interviews, and facility policy review, the facility failed to provide routine scheduled baths for 3 of 3 residents reviewed (Resident #1, #5, #10). The facility reported a census of 98 residents.

Inspectors wroteBased on clinical record review, hospital record review, medical provider, staff, and family interviews and facility policy review, the facility failed to notify the medical provider of orders requiring follow-up upon a resident's admission to the facility following a hospital stay for one of three residents reviewed (Res #10) for medications. The facility reported a census of 98 residents.

Inspectors wroteBased on record review, staff interview, the Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1, and policy/guidance review the facility failed to ensure accuracy on residents' Comprehensive Minimum Data Set (MDS) assessments. Residents reviewed were coded incorrectly indicating their diagnoses were not determined to be a Preadmission Screening and Resident Review (PASRR) condition for 5 of 9 residents reviewed for MDS discrepancies (Residents #4, #7, #8, #53, and #54). The facility reported a census of 93 residents.

Inspectors wroteBased on observation, staff interviews, resident interview, record review and policy, the facility failed to follow professional standards of medication administration for 1 of 4 resident's observed for medication administration (Resident #69). During an observation the staff left medication at bedside. The facility reported a census of 93.

Inspectors wroteBased on observations, clinical record review, staff interview, representative interview and facility policy review the facility failed to provide hand/nail hygiene for 3 of 3 days observed for one of 24 residents reviewed (Resident # 77). The facility reported a census of 93.

Inspectors wroteBased on electronic health record (EHR) review, staff interviews, and policy review, the facility failed to complete neurological checks for a resident with an unwitnessed fall for 1 of 2 residents reviewed for falls (Resident #98). The facility reported a census of 93.

Inspectors wroteBased on electronic health record (EHR) review, staff interviews, and policy review, the facility failed to complete smoking assessments for 1 of 1 residents reviewed for smoking (Resident #4). The facility reported a census of 93.

Inspectors wroteBased on observations, Resident Council Minutes, resident and staff interviews, the facility failed to answer resident call lights within the allotted professional standard of 15 minutes for 3 of 5 residents reviewed (Resident #3, #4 and #11) . The facility reported a census of 97 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure staff protected and prevented resident to resident abuse for 1 of 3 reviewed (Resident #7), when Resident #6 hit Resident #7 a couple of times in the back while in the main lobby area. Resident #7 had a known history of resident-to-resident altercations and the facility failed to evaluate the effectiveness of the interventions to prevent harm to other residents. The facility reported a census of 97 residents.

Inspectors wroteBased on record review, policy review and staff interview, the facility failed to complete incident reports or document for 2 of 3 resident-to-resident altercations reviewed (Resident #6). The facility reported a census of 97 residents.

Inspectors wroteBased on observation, resident interviews, staff interviews and policy review, the facility failed to provide comfortable and safe temperature levels in the building for one of two dinning rooms. The facility reported a census of 90 residents.

Inspectors wroteBased on clinical record review, medication administration log, staff interview, and facility policy review, the facility failed to prepare or administer medication as prescribed and ordered by the physician for 2 of 3 residents reviewed (Resident #2, #7). The facility reported a census of 90.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.