Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Altoona Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Incorrect PASRR Coding on MDS Assessments: The facility failed to accurately code PASRR status on multiple MDS assessments. Several residents with documented PASRR conditions, including mental health disability, ID, DD/RC, schizophrenia, bipolar disorder, PTSD, and dementia-related diagnoses, were marked no in A1500 even though their PASRR documents directed that the MDS reflect those conditions. The MDS process involved a travel MDS nurse completing in-person assessments and a corporate MDS coordinator finalizing other sections from record review, and the coordinator acknowledged the PASRR information was not completed correctly.
Medications Left at Bedside Without Order: A resident with intact cognition and orders for an inhaler and nasal sprays had those medications left in a bag at bedside during observation, even though there was no order allowing bedside storage or self-administration. Staff confirmed the resident wanted the meds left with her and that they were left there because she would scream if she did not get her way; an LPN and the ADON both acknowledged there was no order for bedside medication storage.
Failure to provide hand and nail hygiene for a resident with severe cognitive impairment and ADL dependence. The resident had MS and dementia, and the care plan directed staff to check, trim, and clean nails during bath days and as needed. Surveyors observed dark material under the resident’s fingernails on multiple occasions, including after a meal when a CNA did not perform hand hygiene. The resident’s representative requested better hand hygiene, and staff stated nail care was usually handled by activities staff or during showers.
Missing Quarterly Smoking Assessments: The facility failed to complete required smoking assessments for a resident who smoked and had impaired cognition, dementia, seizure disorder, and a stroke history. EHR review showed only one smoking assessment, while the care plan and Tobacco Policy called for quarterly assessments. Staff confirmed the resident smoked during designated smoke times, and the DON acknowledged the missing assessments.
Failure to complete neuro checks after an unwitnessed fall. A resident with a BIMS of 13, significant transfer/bed mobility assistance needs, a wheelchair, and multiple medical diagnoses was found on the floor after sliding out of bed. The resident said they did not hit their head, but the EHR lacked documentation of neuro checks after the unwitnessed fall; an LPN said checks were done on paper, while the DON believed they were not indicated.
Multiple residents who were dependent on staff for toileting and transfers experienced prolonged delays in call light response, sometimes waiting over an hour for assistance. Residents and staff reported that staffing shortages contributed to these delays, and observations showed that management and nursing staff did not always respond to call lights within the facility's 15-minute standard. Resident Council Meeting minutes documented ongoing complaints about long waits and lack of follow-up.
A resident with a history of dementia and repeated aggressive behaviors, including verbal and physical altercations, struck another resident in a common area. Despite ongoing incidents, staff interventions were limited to separating and redirecting residents, without further evaluation or effective changes to the care plan. Incident reports were inconsistently completed, and there was no root cause analysis or comprehensive approach to prevent recurrence, leaving residents unprotected from further abuse.
Staff did not complete required incident reports or documentation for two resident-to-resident altercations involving a cognitively impaired resident who shoved another resident's wheelchair and used inappropriate language. Although staff intervened verbally, no formal reports or follow-up were conducted, contrary to facility policy.
The facility did not maintain safe and comfortable temperatures in one dining room, where the air conditioning unit was nonfunctional for an extended period. Staff and residents experienced significant discomfort, with some residents choosing to eat in their rooms due to the heat. A resident with COPD was unable to tolerate the dining room temperature and had to finish her meal elsewhere. The facility's policy requires temperatures between 71°F and 81°F, but this was not achieved during the incident.
Two residents did not receive their prescribed medications as ordered, with one missing multiple insulin doses and another missing several doses of prescribed eye drops due to unavailability. Documentation in the MAR was incomplete, and residents reported missed or delayed medications, leading to elevated blood glucose and discomfort. Staff interviews confirmed knowledge of procedures, but there was no available policy on medication administration accuracy.
The facility failed to effectively address repeated deficiencies in infection prevention and control, as evidenced by multiple non-harm level citations for improper glove usage and infection control practices. Despite previous corrective actions, the facility continued to receive citations, indicating an ineffective QAPI process. Additional deficiencies were noted in maintaining a safe environment and providing adequate ADL care.
The facility failed to provide a homelike environment due to continuous loud alarms and cluttered hallways. Residents were disturbed by constant beeping sounds from call light and door alarms, and hallways were obstructed by equipment, hindering safe navigation. A resident was found repeatedly without bed linens, indicating neglect in personal care. Staff interviews confirmed the persistent noise and lack of storage space, contributing to the disorganized environment.
The facility failed to provide adequate assistance with ADLs for four residents, leading to deficiencies in personal care and hygiene. A resident with impaired vision had overgrown and soiled fingernails despite requesting assistance. Another resident with dementia was observed with unshaved facial hair and greasy hair, with incomplete documentation of grooming. A third resident expressed uncertainty about receiving showers, and a fourth resident reported infrequent showers due to staff excuses. Staff interviews revealed inconsistent documentation and follow-up on care refusals.
The facility failed to ensure safe transfers for residents, secure smoking materials, and maintain clear hallways. A resident was pushed in a wheelchair without foot pedals, another was transferred without a gait belt, and smoking materials were unsecured for a cognitively impaired resident. Hallways were cluttered, impeding mobility and creating hazards.
The facility failed to provide sufficient nursing staff, leading to delayed care for residents. Observations showed residents waiting for assistance during meals, and interviews revealed long response times to call lights and inadequate help with transfers. Staff expressed frustration over staffing ratios, and reviews of schedules confirmed frequent shortages, impacting resident care.
A resident with a history of sepsis and a supra pubic catheter experienced recurring urinary tract infections due to improper catheter care. The catheter tubing was observed dragging on the floor while the resident was in a wheelchair, contrary to facility policy. The ADON acknowledged the issue, highlighting the risk of infection from such practices.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer. An LPN did not wear a gown during wound care, despite signs indicating the need for gowns and gloves. Additionally, a CNA reported not understanding EBP protocols, highlighting a gap in staff training. The facility's policy required gowns and gloves during high-contact care to prevent the spread of multi-drug resistant organisms, but compliance was not ensured.
The facility failed to maintain resident dignity and privacy for two residents. A resident with paraplegia was observed in the dining room wearing an open hospital gown, as staff did not assist with dressing. Another resident, requiring two-person assistance for toileting, was exposed to his roommate due to staff not closing the privacy curtain. Both residents had intact cognition and expressed concerns about these incidents.
A resident with multiple health issues and intact cognition did not receive ordered rehabilitative services due to a communication failure and process change within the facility. Despite recommendations for a restorative program, the resident reported not receiving services, and the facility was unable to determine the cause of the oversight.
A facility failed to coordinate medication management with hospice services for a resident on hospice care, leading to concerns about overmedication and lack of communication. The resident, with a terminal illness, experienced frequent medication changes and disagreements between facility and hospice staff regarding the appropriateness of medications like Lorazepam and Seroquel. The facility's electronic health record lacked documentation of communication about antipsychotic management, contributing to the deficiency.
The facility failed to provide adequate perineal care and bathing services, as staff reported finding residents with soiled undergarments and bedding. A resident with a neurogenic bladder and arthritis missed multiple scheduled baths, and the facility's Resident Council Minutes noted concerns about inadequate bathroom care and staffing issues.
The facility failed to secure treatment carts on two occasions, leaving them unlocked and unattended outside resident rooms. The facility's policy required carts to be locked when not in view, especially since eight residents were identified as wanderers. The Administrator confirmed the expectation for staff to lock carts when unattended.
The facility failed to provide restorative exercises according to the care plans for two residents, impacting their range of motion and mobility. One resident, with conditions including Neurogenic Bladder and Arthritis, did not receive prescribed lower extremity and standing exercises. Another resident missed upper and lower extremity exercises. These deficiencies were identified through record reviews and interviews.
A resident with dementia and a history of falls eloped from the facility due to inadequate supervision and a malfunctioning wander guard system. The resident, who was at risk for elopement, managed to leave the facility without her walker and was found outside by staff. Interviews revealed that staff were not adequately trained on elopement risks, and the wander guard system was non-functional due to a lack of electricity.
The facility failed to maintain the walk-in freezer and refrigerator in a clean and satisfactory condition, leading to frost and drip issues that were not reported to the maintenance supervisor. Staff were aware of the problem for at least five years, but the facility's policy on monthly inspections and immediate repairs was not followed.
The facility failed to maintain a clean, comfortable, and homelike environment, with strong odors of ammonia and feces in hallways, cluttered pathways obstructing residents' movement, and visible stains resembling fecal matter in a resident's bathroom. These issues were observed in various hallways and rooms, indicating non-compliance with the facility's policy on maintaining a homelike setting.
The facility failed to notify a resident's representative of a room change. The resident, with moderate cognitive impairment, had a family member involved in health discussions who was not informed of the change. This was confirmed by both the family member and the facility's administrator, violating the facility's policy on room change notifications.
The facility failed to accurately code MDS assessments for two residents, leading to discrepancies in the documentation of a PASRR level II evaluation and the use of bed rail restraints. One resident was inaccurately coded as not having a PASRR level II evaluation despite documented psychiatric disorders and antipsychotic medication use. Another resident was incorrectly coded for daily bed rail use, which was not observed or documented.
The facility failed to provide restorative activities for three residents, leading to a decline in their ability to perform activities of daily living. Despite therapy recommendations, the residents' restorative programs were not documented or followed, resulting in a lack of necessary care.
The facility failed to provide sufficient and competent staff, leading to delays in bathroom care and call light responses. A resident with severe cognitive impairment was found in a soiled state, and staff confirmed frequent understaffing. Residents reported long wait times for assistance, and a CNA was found sleeping during their shift, highlighting significant staffing issues.
The facility failed to notify the LTC ombudsman of a resident's transfer to an acute care hospital due to issues with the Electronic Health Record system. The resident was transferred after making suicidal statements, but the transfer was not reported correctly.
The facility failed to update and revise Care Plans to reflect therapy recommendations for restorative activities programs for three residents. Despite receiving therapy, the Care Plans lacked information on restorative nursing programs, and the DON missed entering these programs into the EHR during the transition from paper documentation, leading to staff being unaware of the need for restorative exercises.
The facility failed to properly transcribe and implement provider orders for a resident with multiple skin integrity issues, resulting in the ordered wound treatment not being administered. Staff interviews revealed lapses in the facility's triple-check process for transcribing orders.
A resident with intact cognition and likely cavities did not receive requested dental services despite multiple requests. Staff claimed the resident refused care, but the resident denied this and expressed willingness to receive dental care.
Facility staff failed to follow infection control practices, including improper glove use and hand hygiene, and did not disinfect soiled resident care devices. These lapses were observed during incontinence care and meal assistance for multiple residents.
The facility failed to provide education and administration of pneumococcal immunization for 28 eligible residents, including two specific residents who lacked documentation of receiving the Prevnar 20 vaccine despite being eligible and having consent. An audit identified the deficiency, and the Infection Preventionist/DON confirmed the issue.
Incorrect PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to ensure accurate Comprehensive MDS assessments for residents with PASRR conditions. Record review showed that 5 of 9 residents reviewed for MDS discrepancies were coded incorrectly in Section A1500 as not currently considered by the state to have a level II PASRR condition, even though their PASRR documents identified qualifying mental health, intellectual disability, developmental disability, or related conditions. The residents involved were identified as having diagnoses including dementia, anxiety disorder, depression, psychotic disorder, schizophrenia, bipolar disorder, PTSD, cerebral palsy, intellectual disability, and developmental disability/related condition. For Resident #4, the MDS documented a BIMS score of 9 and diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, and schizophrenia, but A1500 was marked no despite a PASRR showing level I positive with mental health disability and intellectual disability and directing that A1500 be marked yes and A1510 completed. Resident #7's MDS also showed a BIMS score of 9 with anxiety disorder, depression, bipolar disorder, and PTSD, yet A1500 was marked no even though the PASRR identified a level I positive with mental health disability and instructed that the PASRR condition be documented on the MDS. Resident #8's MDS showed a BIMS score of 15 and diagnoses of cerebral palsy, anxiety disorder, depression, schizophrenia, and PTSD, but A1500 was marked no despite a PASRR identifying mental health disability, intellectual disability, and developmental disability/related condition. Resident #53's MDS documented a BIMS score of 99 and diagnoses of non-Alzheimer's dementia and bipolar disorder, and Resident #54's MDS documented a BIMS score of 15 with anxiety disorder, depression, and bipolar disorder; both were also coded no in A1500 even though their PASRRs identified qualifying PASRR conditions and directed that the MDS reflect those findings. During interview, the Corporate Offsite MDS Coordinator stated the travel MDS nurse completed in-person assessments, while the coordinator completed other MDS areas from document review and finalized the assessments, and acknowledged the PASRR information was not completed correctly and that there was not a complete understanding of PASRR documentation. The facility policy stated that all MDS sections must be clearly assigned and that the RN Coordinator attests to timely completion of the RAI, and the LTC Facility RAI 3.0 User's Manual directed coding yes when PASRR level II screening determined the resident had a serious mental illness.
Medications Left at Bedside Without Order
Penalty
Summary
The facility failed to follow professional standards of medication administration for 1 of 4 residents observed during medication administration, involving a resident with a BIMS score of 15 indicating cognition intact and diagnoses of diabetes, heart disease, lung disease, and kidney disease. The resident’s March 2026 MAR included orders for an albuterol inhaler, ipratropium bromide nasal solution, and fluticasone propionate nasal suspension. During observation, the resident was sitting at bedside with a tray table in front of her, and a clear plastic bag containing two inhalers and a medicated nasal spray was observed at the bedside. The resident stated the medication belonged to her and that staff left it with her. Staff interviews confirmed the medications were left at the resident’s bedside without an order allowing bedside storage or self-administration. A CMA stated the resident wanted her medications left with her and that staff usually stayed with her until she took them, but the medications were left at the bedside because she would scream if she did not get her way. An LPN confirmed the resident did not have orders to keep medications at her bedside and stated she would remove them and place them in the locked medication cart. The ADON also acknowledged there was no order for bedside medication storage and referenced the facility’s self-administration policy, which requires consideration of appropriateness, safety, cognitive status, and ability, and states bedside storage is only permitted when it does not present a risk to confused residents.
Failure to Provide Hand and Nail Hygiene
Penalty
Summary
The facility failed to provide hand and nail hygiene for a resident who was unable to perform activities of daily living independently. Resident #77 had a BIMS score of 2, indicating severe cognitive impairment, and the MDS listed diagnoses of multiple sclerosis and dementia. The care plan identified a self-care deficit and directed staff to provide nail care by checking, trimming, and cleaning nails during bath days and whenever needed. A policy titled Nail Care instructed staff to provide routine cleaning and inspection of nails during care on an ongoing basis. During observations, the resident was seen with a brownish dark substance under the fingernails on multiple days. The resident's representative stated the resident's cleanliness could improve and specifically requested better hand hygiene. Staff observed the resident after a meal without performing hand hygiene, and the resident continued to have dark, brownish material under the fingernails. When questioned, CNAs stated nail care was typically handled by activities staff once a week or during showers. The ADON stated staff had access to a small tool to clean under nails and believed the material was likely food because the resident ate with their hands; the ADON also noted the resident liked to eat with their hands and had a sign in the room asking staff to help clean the wheelchair and the resident after each meal.
Missing Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete smoking assessments for 1 of 1 residents reviewed for smoking, Resident #4. The resident’s MDS assessment completed 3/12/26 showed a BIMS score of 10, indicating impaired cognition, and diagnoses included non-Alzheimer’s dementia, seizure disorder, and stroke. The care plan indicated the resident smoked and included completion of quarterly smoking assessments, and the facility acknowledged that Resident #4 was on the list of current residents who smoke. Review of the EHR showed a smoking assessment completed on 3/12/26, but no additional smoking assessments were identified to match the resident’s quarterly MDS assessments dated 4/30/25, 7/28/25, 10/23/25, and 1/21/26. Staff interviews confirmed the resident went out to smoke during designated smoke times and that smoking safety devices are identified through smoking assessments completed by nursing staff. The DON acknowledged the lack of smoking assessments, and the facility’s Tobacco Policy stated residents who wish to use tobacco/smoke are to be evaluated for safe smoking upon admission and quarterly.
Failure to Complete Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to complete neurological checks after an unwitnessed fall for one resident. Resident #98 had a BIMS score of 13, required substantial to maximum staff assistance for transfers and bed mobility, used a wheelchair, and had diagnoses including anemia, diabetes, insomnia, and osteomyelitis at the right lower leg/foot amputation site. The care plan identified the resident as a fall risk due to impaired balance, recent amputation, poor safety awareness, and impaired neuromuscular function, and it documented a fall on 1/17/26. After the resident was found on the floor, nursing staff assessed the resident and returned them to bed using a mechanical lift. The resident stated they had tried to sit on the edge of the bed and slid out, and said they did not hit their head. The incident was unwitnessed, and the EHR did not contain documentation of neurological checks after the fall. During interviews, the LPN stated neurological checks were started and documented on paper and handed off to the next nurse, while the DON stated neurological checks were not thought to be indicated because the resident had a higher BIMS score and said they did not hit their head.
Failure to Timely Respond to Resident Call Lights Due to Inadequate Staffing
Penalty
Summary
Surveyors identified that the facility failed to provide adequate nursing staff to meet the needs of residents, specifically in timely response to call lights. Multiple observations and interviews revealed that residents who were dependent on staff for toileting and transfers experienced significant delays, with call lights remaining unanswered for extended periods, sometimes up to an hour and a half or more. Residents reported tracking the time it took for staff to respond, and noted that delays were less frequent during the survey period due to increased office staff involvement. Resident Council Meeting minutes from several months documented ongoing complaints about long waits for call lights, staff not returning as promised, and residents being left on the toilet for over 30 minutes, with no documented follow-up on these concerns. Staff interviews confirmed that staffing shortages contributed to the delays in answering call lights, with CNAs stating that they were sometimes unable to respond promptly due to insufficient staff, especially during call-ins. Observations included instances where management and nursing staff walked past rooms with active call lights without responding, and residents reported having to call the facility to get assistance. The Director of Nursing and Administrator acknowledged the expectation for call lights to be answered within 15 minutes, but this standard was not consistently met, as evidenced by the documented delays and resident reports.
Failure to Prevent Resident-to-Resident Abuse and Inadequate Behavioral Intervention
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, specifically when one resident with a history of aggressive behaviors struck another resident in the main lobby area. The resident who initiated the altercation had a documented history of dementia, moderately impaired cognition, and repeated episodes of verbal and physical aggression toward other residents, including name-calling, cursing, shoving, and hitting. Despite these ongoing incidents, the facility's interventions were limited to separating residents and redirecting them, without further evaluation or implementation of additional measures to prevent recurrence. Clinical record reviews and staff interviews revealed that the aggressive resident had multiple documented incidents of both verbal and physical aggression over several months, including shoving other residents, using offensive language, and physically striking or pushing others. Staff responses were generally limited to verbal reminders, redirection, or asking other residents to move, rather than addressing the root causes or modifying the care plan with more effective interventions. Incident reports were not consistently completed, especially when no physical injury was observed, and there was a lack of root cause analysis or a resident-centered approach to prevent further incidents. The facility's abuse prevention policy requires protection of residents from all forms of abuse, including resident-to-resident physical contact that results in harm, pain, or mental anguish. However, the facility did not adequately assess or address the ongoing behavioral issues of the aggressive resident, nor did it evaluate the effectiveness of existing interventions. Staff interviews indicated a general awareness of the resident's behaviors, but also a normalization of avoidance strategies rather than proactive prevention, leaving other residents vulnerable to further abuse.
Failure to Document and Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to complete incident reports or document two resident-to-resident altercations involving a resident with moderately impaired cognition, dementia, and diabetes. The resident was documented in progress notes as having shoved another resident's wheelchair and used inappropriate language on multiple occasions. Staff intervened verbally at the time of the incidents but did not complete incident reports or document follow-up with the other residents involved. The Director of Nursing confirmed that no incident reports were completed for these events because no injuries occurred. Staff interviews revealed that the LPN involved did not chart or follow up with the other residents involved in the altercations and did not recall specific details about the incidents. The facility's policy required that all accidents or incidents involving residents be investigated and reported, including documentation of circumstances, those involved, and corrective actions taken. Despite this policy, the required documentation and reporting were not completed for the incidents in question.
Failure to Maintain Safe and Comfortable Dining Room Temperatures
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature in one of its dining rooms, resulting in uncomfortably high temperatures for residents and staff. Observations showed that the thermostat in the back dining room read 83 degrees, and both staff and residents exhibited signs of discomfort, such as flushed faces and sweating. The air conditioning unit in the dining room had been nonfunctional since Sunday, and the temperature in the room was reported to be in the high 80s or low 90s during this period. Despite the heat, residents continued to eat meals in the dining room, although they were given the option to eat in their rooms. Staff interviews confirmed that the air conditioning unit had been freezing up and was out of service for an extended period, with maintenance unable to secure immediate repairs. Staff described the environment as very uncomfortable, and some residents chose to eat in their rooms due to the heat. One staff member noted that a resident with COPD was unable to tolerate the dining room temperature and had to finish her meal in her room. Fans were used in the dining room, but they did not sufficiently cool the area. Resident interviews corroborated the staff's accounts, with residents reporting significant discomfort, loss of appetite, and sweating while eating in the dining room. The facility's policy requires maintaining comfortable and safe temperatures between 71°F and 81°F, but this standard was not met in the back dining room during the period in question. The deficiency was observed through direct observation, staff and resident interviews, and review of facility policy.
Failure to Administer and Document Prescribed Medications
Penalty
Summary
The facility failed to ensure that medications were prepared and administered as prescribed for two residents. For one resident with diabetes, there were multiple instances where documentation was missing for both Insulin Lispro and Lantus administrations, particularly during evening doses. The missing documentation coincided with elevated blood glucose readings, and the resident reported missing at least three doses in the past month, often needing to remind staff to administer her insulin. She described feeling unwell when doses were missed and noted that the issue primarily occurred during evening medication rounds. The care plan for this resident required staff to administer medications as ordered and monitor for signs of hyperglycemia and hypoglycemia, but these instructions were not consistently followed. Another resident with glaucoma and macular degeneration was prescribed daily Latanoprost eye drops, but the medication was marked as unavailable and not administered on several occasions over a span of days. The resident reported discomfort and was told by staff that the medication was unavailable for at least a week. Staff interviews revealed that nurses were aware of the procedures for medication administration and documentation, and the DON confirmed that the only documentation for medication administration was in the MAR. However, there was no available policy on the accuracy of medication administration, and staff were unfamiliar with the specific instances of missed doses for these residents.
Repeated Deficiencies in Infection Control and Staff Education
Penalty
Summary
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 deficiencies were primarily related to infection prevention and control, as evidenced by non-harm level citations received during recertification and complaint surveys conducted on several occasions. These citations highlighted issues with the proper usage of gloves during perineal care and for patients in isolation, as well as general infection control practices. The facility's Plan of Correction (POC) documents from previous surveys revealed that the facility had been cited for similar deficiencies multiple times, indicating a pattern of non-compliance with infection control procedures. Despite efforts to educate staff and implement corrective measures, such as conducting staff education sessions and audits, the facility continued to receive citations for infection prevention and control. This suggests that the facility's QAPI process was not effectively addressing the root causes of these deficiencies. The facility's current recertification survey also identified repeated non-harm level deficient practices in other areas, including maintaining a safe, clean, and comfortable environment, providing adequate activities of daily living (ADL) care, and ensuring sufficient nursing staff. The facility administrator acknowledged these repeat deficiencies and noted that a new RN Education position had been created to address ongoing staff education and compliance issues, although the current RN in this role was not meeting the position's criteria.
Facility Fails to Maintain Homelike Environment Due to Noise and Clutter
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for its residents, as evidenced by multiple observations of loud, continuous beeping sounds and cluttered hallways. The beeping, identified as call light and door alarms, was consistently audible in various halls, causing disturbances throughout the day and night. Staff interviews confirmed that these alarms were a constant presence, contributing to increased resident agitation and difficulty sleeping. Additionally, the facility's hallways were frequently obstructed by equipment such as wheelchairs, mechanical lifts, and linen carts, which impeded residents' ability to navigate the space safely and independently. Resident #54 was observed multiple times lying on a bed without sheets or linens, with a strong odor of urine emanating from the mattress. Despite the resident's intact cognition and ability to communicate, the issue persisted over several days, indicating a lack of attention to personal care needs. The Director of Nursing and the Administrator were unaware of the situation, suggesting a breakdown in communication and oversight regarding resident care and environmental conditions. The facility's policy on maintaining a homelike environment was not adhered to, as evidenced by the persistent noise levels and disorganized hallways. Staff interviews revealed that the facility lacked adequate storage space, leading to the accumulation of equipment in common areas. The combination of noise pollution and physical obstructions in the hallways compromised the residents' quality of life, as they were unable to enjoy a peaceful and orderly environment as promised by the facility's policy.
Deficiencies in Resident Care and Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, leading to deficiencies in personal care and hygiene. Resident #84, with intact cognition and multiple health issues including impaired vision, was observed with overgrown and soiled fingernails. Despite requesting assistance for a week, his nails had not been trimmed since his admission. Staff interviews confirmed that nail care documentation was inconsistent and that the resident's nails had not been attended to as required by the care plan. Resident #12, who has non-Alzheimer's dementia and requires substantial assistance with ADLs, was observed with unshaved facial hair, long and broken fingernails, and greasy hair. The documentation of her showers and grooming was incomplete, and there was no record of her refusing care during the observed period. Staff interviews revealed expectations for regular grooming and documentation, but these were not met, leading to the resident's unkempt appearance. Resident #58, with intact cognition and a history of refusing showers, was not documented as having received any showers since admission. The resident expressed uncertainty about receiving showers, and staff interviews indicated a lack of proper documentation and follow-up on refusals. Similarly, Resident #3, who requires assistance from multiple staff members for bathing, reported infrequent showers and staff excuses for not providing care. The electronic records showed inadequate documentation of showers, highlighting a systemic issue in the facility's care provision and record-keeping.
Deficiencies in Resident Safety and Environmental Management
Penalty
Summary
The facility failed to ensure safe and appropriate transfer practices for several residents, leading to potential safety hazards. Resident #12, who had a history of falls and required substantial assistance for transfers, was observed being pushed in a wheelchair without foot pedals, causing her feet to move back and forth on the floor. This was against the facility's expectations as confirmed by the Assistant Director of Nursing (ADON). Similarly, Resident #19, who also required substantial assistance and had a history of falls, was transferred without the use of a gait belt, and the wheelchair brakes were not locked, leading to an unstable and unsafe transfer. The facility also failed to secure smoking materials for Resident #79, who had severely impaired cognition. Cigarettes were found in the resident's room on multiple occasions, contrary to the care plan that required cigarettes to be kept in a locked area. Staff interviews confirmed that cigarettes should be secured, and the facility's tobacco policy emphasized safe practices for resident cigarette use. Additionally, the facility did not maintain clear and clutter-free hallways, which impeded resident mobility and created potential hazards. Observations revealed numerous wheelchairs, carts, and other equipment blocking the hallways, making it difficult for residents to navigate. Staff interviews acknowledged the persistent issue of cluttered hallways, which had been a problem in previous surveys and was supposed to be addressed through a performance improvement plan, but remained unresolved.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews. During a breakfast dining observation, it was noted that three residents at an assisted feeding table were not served their meals promptly, with one resident left unattended with his food untouched for several minutes. Interviews with residents revealed concerns about delayed responses to call lights, with one resident reporting waits of 45 minutes to 2 hours. This resident also expressed concerns about inadequate assistance with transfers, which were often performed by only one staff member instead of the required two. Staff interviews further highlighted the staffing issues, with several CNAs and RNs expressing frustration over the inadequate staffing levels. One RN mentioned the intention to quit due to the "insane" staffing ratios, which left only three staff members to care for approximately 46 residents on one unit. CNAs reported that residents were not being offered showers regularly, and call lights and alarms were often left unanswered for extended periods, indicating a struggle to keep up with resident needs due to insufficient staffing. A review of the facility's staffing schedules and CMS Payroll Based Journal data corroborated these concerns, showing excessively low weekend staffing levels and frequent instances of inadequate CNA coverage. The facility's staffing plan outlined a need for more CNAs per shift than were actually present, with frequent call-ins and no-shows exacerbating the issue. The Scheduling Coordinator acknowledged these challenges and noted efforts to cover shifts personally, but the persistent staffing shortages continued to impact the quality of care provided to residents.
Inadequate Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate intervention for a resident with a urinary catheter, leading to recurring urinary tract infections. The resident, who had a history of sepsis, pneumonia, and a supra pubic catheter, was observed with the catheter tubing dragging on the floor while being transported in a wheelchair. This observation was made despite the facility's policy that catheter tubing and drainage bags should be kept off the floor to prevent infections. During an interview, the resident's responsible party mentioned a recent hospitalization for pneumonia and a urinary tract infection. The Assistant Director of Nurses was informed of the issue and acknowledged that the catheter bag should be hung higher to prevent the tubing from touching the floor. The facility's policy, revised in August 2022, emphasizes the importance of keeping catheter equipment off the floor to avoid complications such as urinary tract infections.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) and infection control practices for a resident with a Stage 3 pressure ulcer on the left heel. The resident, who required substantial to maximum assistance for transfers, was on EBP due to the wound. Observations revealed that although signs were posted indicating the need for gowns and gloves during high-contact care activities, a Licensed Practical Nurse (LPN) did not wear a gown while performing wound care on the resident. The LPN sanitized her hands, donned gloves, and performed the wound care procedure, but failed to comply with the EBP requirement of wearing a gown. Additionally, there was a lack of understanding among staff regarding EBP protocols. A certified nursing assistant reported not understanding what EBP's were, indicating a gap in staff training and awareness. The facility's policy on EBP, dated March 2024, required gowns and gloves during high-contact care activities to prevent the spread of multi-drug resistant organisms. Despite the policy and the presence of signs and personal protective equipment, the facility did not ensure compliance, leading to a deficiency in infection control practices.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents' dignity by not providing adequate dressing assistance and disregarding privacy for two residents. Resident #89, who has non-traumatic spinal cord dysfunction and paraplegia, was observed in the main dining room wearing a hospital gown that was open at the back, exposing his skin. Despite having intact cognition and requiring substantial assistance with dressing, staff did not offer to help him dress appropriately before the meal, citing that they were too busy. The facility's policy on dignity emphasizes that residents should be encouraged to dress in clothing they prefer, which was not adhered to in this instance. Resident #84, who has heart failure, hypertension, renal insufficiency, and impaired vision, required two-person assistance for toileting. During an observation, staff used a mechanical lift to assist him to the restroom but did not close the privacy curtain, exposing his genital area to his roommate, Resident #74. Resident #74, who also has intact cognition, expressed discomfort with the lack of privacy during these instances, stating that staff never pull the curtain when assisting his roommate.
Failure to Provide Rehabilitative Services as Ordered
Penalty
Summary
The facility failed to provide rehabilitative services as ordered for Resident #84, who was one of the 24 residents reviewed. Resident #84 had a BIMS score of 15, indicating intact cognition, and had multiple diagnoses including heart failure, hypertension, renal insufficiency, stroke, seizure disorder, malnutrition, acute respiratory failure, muscle weakness, and difficulty in walking. The resident was dependent on staff for transferring, ambulation, and personal care. The care plan indicated that physical therapy (PT) and occupational therapy (OT) would evaluate and treat as ordered, but it did not include a restorative plan. Despite recommendations from PT and OT for a restorative program to maintain gains and prevent decline, the resident did not receive these services. The deficiency occurred due to a failure in communication and process changes within the facility. An order to start restorative services for Resident #84 was documented with a start date of 02/13/2025, but the resident reported not receiving any rehabilitative services. The Director of Rehabilitative Services and the Director of Nursing confirmed that the facility had recently changed the process for confirming receipt of restorative orders, which led to the oversight. The facility was unable to determine who was at fault for the failure, and the resident expressed a desire to get stronger to have a chance of going home, but felt unsupported in achieving this goal.
Deficiency in Coordination of Hospice Medication Management
Penalty
Summary
The facility failed to effectively coordinate medication management with hospice services for a resident receiving hospice care, leading to a deficiency. The resident, who had a life expectancy of less than six months, was on hospice for worsening Major Depressive Disorder with anxiety and persistent complications from gastric bypass surgery. The resident's care plan included hospice services, and interventions were in place to manage symptoms of pain and discomfort. However, the facility's electronic health record lacked documentation of communication between facility staff and hospice regarding the management of antipsychotic medications, and there were concerns about the resident being overmedicated. The report highlights several instances of miscommunication and lack of coordination between the facility and hospice staff. On multiple occasions, hospice RNs communicated with facility staff about the resident's medication regimen, but there were disagreements and concerns about the appropriateness of the medications, particularly Lorazepam and Seroquel. The facility's Administrator and DON expressed concerns about the resident being overmedicated and the potential violation of CMS regulations. Despite these concerns, hospice staff believed the medication regimen was appropriate for managing the resident's terminal restlessness and anxiety. Interviews with facility and hospice staff revealed ongoing issues with medication management and communication. Facility staff were unsure why hospice was not taking the lead in managing antipsychotic medications, and there were frequent changes to the resident's medication orders. The hospice medical director believed the facility was more guarded with antipsychotic management, and there was a suspicion that the facility's actions were aimed at reducing resident risk rather than maintaining comfort. The contract between the facility and hospice outlined the responsibilities for managing the resident's care, but the lack of effective coordination led to the deficiency.
Deficiency in Resident Hygiene and Bathing Services
Penalty
Summary
The facility failed to provide adequate perineal care and bathing services to residents, as evidenced by multiple staff interviews and resident complaints. Certified Nursing Assistants (CNAs) reported finding residents in bed with soiled disposable undergarments and bedding, indicating that residents had not been changed for extended periods. Additionally, a CNA/Shower aide confirmed that due to staffing issues, she was unable to shower residents according to their schedules, leading to complaints from residents. The facility's failure to maintain proper hygiene for residents was further corroborated by observations of dried stool and urine on residents and their bedding. A specific case involved a resident with a neurogenic bladder, urinary tract infections, and arthritis, who required assistance with activities of daily living. The resident's care plan included bathing twice a week, but records showed multiple missed bathing dates over several months. The resident confirmed that staff failed to bathe her as scheduled and did not offer alternative methods like bed/chair baths. The facility's Resident Council Minutes also documented concerns about inadequate bathroom care and the reassignment of shower aides to other duties, contributing to the deficiency in care.
Unattended and Unlocked Treatment Carts
Penalty
Summary
The facility failed to maintain a locked treatment cart on two separate occasions, as observed by surveyors. On the first occasion, an unlocked and unattended treatment cart was found along the wall outside of room N6. On the second occasion, another unlocked and unattended treatment cart was observed outside of room A46. The facility had identified eight residents who wandered, which could pose a risk if they accessed the unlocked carts. The facility's policy on the security of medication carts required that carts be secured during medication passes and remain locked when out of the nurse's view. The Administrator confirmed that staff were expected to lock medication and treatment carts when unattended.
Failure to Provide Restorative Exercises as Per Care Plans
Penalty
Summary
The facility failed to provide restorative exercises according to the individual care plans for two residents, leading to a deficiency in maintaining or improving their range of motion and mobility. Resident #2, who was cognitively intact with a BIMS score of 15, had diagnoses including Neurogenic Bladder, UTIs, and Arthritis, and required assistance with most ADLs. The resident's care plan included bilateral lower extremity exercises with ankle weights and standing exercises with a front-wheeled walker. However, these exercises were not provided on multiple dates between early July and early August, as confirmed by the resident. Similarly, Resident #5's care plan required bilateral upper extremity exercises with dumbbells and bilateral lower extremity exercises, including marches, hip flexion, abduction, and ankle pumps. These exercises were also not provided on several dates within the same period. The facility's failure to adhere to the prescribed exercise regimen for these residents was identified through clinical record reviews and interviews, highlighting a lapse in the implementation of restorative programs as per the residents' care plans.
Resident Elopement Due to Inadequate Supervision and Malfunctioning Wander Guard System
Penalty
Summary
The facility failed to maintain a safe and secure environment for a resident identified as being at risk for elopement. The resident, who had a history of hypertension, non-Alzheimer's dementia, depression, and repeated falls, was assessed as having moderately impaired cognitive skills and was independent with ambulation. Despite being at risk for falls and elopement, the resident managed to leave the facility without supervision. On one occasion, the resident was found outside the facility by dietary staff, having removed her wander guard device, which was later found in her bedside drawer with the band cut beside a butter knife. The facility's staff interviews revealed a lack of awareness and training regarding residents at risk for elopement. A CNA who encountered the resident exiting the facility was unaware of the resident's identity and risk status. Additionally, other staff members, including CNAs and a registered nurse, confirmed they had not been oriented on which residents were at risk for elopement or who wore wander guard devices. The facility's elopement policy was not effectively communicated to staff, contributing to the resident's unsupervised exit. Further investigation revealed that the wander guard system was non-functional due to a lack of electricity, as confirmed by maintenance staff. This malfunction was discovered during an observation with the Director of Nursing. The facility's failure to ensure the functionality of the wander guard system and adequately train staff on elopement risks and procedures led to the resident's unsupervised exit, highlighting deficiencies in maintaining a safe environment for residents at risk of elopement.
Failure to Maintain Walk-In Freezer and Refrigerator
Penalty
Summary
The facility failed to maintain the combination walk-in freezer and refrigerator in a clean and satisfactory condition. Observations revealed that frost in the freezer had recently melted, forming an icicle that dripped on an open box of chicken. The icicle was approximately six inches in length at the time of the initial observation. Staff interviews indicated that the frost and drip issue had been ongoing for at least five years, with dietary supervisors and kitchen staff being aware of the problem but not reporting it to the maintenance supervisor. The maintenance supervisor confirmed that he was not made aware of the issue and noted that there had been no service to the freezer in the five months since he was employed by the facility. A review of the maintenance log showed that the refrigerator and freezer combo had last been serviced on 01/20/23, with the replacement of a new fan blade and fan motor for the walking refrigerator portion of the unit. The facility's undated policy on refrigerators and freezers stated that supervisors are required to inspect these units monthly for various conditions and initiate necessary repairs immediately. However, this policy was not followed, leading to the ongoing frost and drip issue in the freezer.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. Observations revealed strong, pungent odors of ammonia and urine in various hallways, particularly near rooms A40, A42, A44, A46, W34, and W32. The odors were traced to dirty linen bins that were not properly sealed, with visible soiled incontinence pads. Additionally, a strong bowel/feces odor was noted from room N6 to N10, with similar issues of unzipped linen bins. The facility's policy on maintaining a homelike environment, which includes minimizing institutional odors and keeping a clean and sanitary environment, was not adhered to as evidenced by these observations. Further observations highlighted cluttered hallways, with mechanical lifts, wheelchairs, weight scale chairs, and other equipment obstructing pathways. This clutter caused difficulties for residents attempting to navigate the hallways, as seen when several residents were unable to pass through due to the congestion. One resident expressed frustration at being unable to exit his room due to the obstruction caused by equipment. Additionally, room N8 was found to have hand-size stains of dark brown color, resembling fecal matter, on the bathroom door and trim, which was confirmed by a housekeeping aide. These deficiencies indicate a failure to provide a clean and safe environment for the residents.
Failure to Notify Resident's Representative of Room Change
Penalty
Summary
The facility failed to promptly notify the resident's representative of a room change for Resident #242, who had a moderate cognitive impairment with a BIMS score of 12. The resident's daughter, who was involved in discussions about the resident's health status and changes since admission, was not informed of the room change. This was confirmed during an interview with the resident's daughter and the facility's administrator. The facility's policy, revised in March 2021, mandates notification prior to any room or roommate assignment changes, which was not followed in this instance.
Inaccurate MDS Coding for PASRR and Bed Rail Use
Penalty
Summary
The facility failed to accurately code resident MDS assessments, leading to discrepancies in the documentation of resident conditions for two residents. Resident #2 was inaccurately coded as not having a PASRR level II evaluation despite having documented psychiatric and mood disorders, including anxiety, depression, bipolar depression, psychotic disorder, and schizophrenia. The resident was also on antipsychotic medication, and the clinical records confirmed a PASRR level II evaluation had been completed. The MDS Coordinator, who worked remotely and was in the facility three times a week, was not immediately available to address the issue, leading to a delay in correcting the MDS coding error. Resident #47 was inaccurately coded for the use of bed rail restraints. The MDS assessment indicated daily use of bed rails, but observations and interviews with the resident's son confirmed that no bed rails were installed or used. The clinical record also lacked documentation of a bed rail assessment. The error was attributed to another MDS Coordinator who was in training. The MDS Coordinator corrected the error upon discovery, but the initial inaccurate coding remained a deficiency in the facility's documentation practices.
Failure to Provide Restorative Activities for Residents
Penalty
Summary
The facility failed to provide restorative activities for three residents, leading to a decline in their ability to perform activities of daily living. Resident #19, who had diagnoses of congestive heart failure, chronic kidney disease, and cancer, was independent with bed mobility, toileting, and transfers. Despite recommendations from occupational and physical therapy for a restorative nursing program (RNP), there was no documentation of restorative activities being performed. The Director of Nursing (DON) confirmed that the resident's restorative program was not entered into the electronic health record (EHR), leading to staff being unaware of the need for restorative exercises. Resident #28, who had a history of stroke and spastic hemiplegia, was dependent on staff for eating, transfers, toileting, and bed mobility. The resident had impaired range of motion in both upper and lower extremities. Despite recommendations from therapy for a restorative program to manage contractures and prevent further decline, there was no documentation of restorative activities being performed. The DON confirmed that the resident's restorative program was not listed in the EHR, and staff were unaware of the need for restorative exercises. Resident #44, who had a history of stroke with hemiplegia, diabetes, and other conditions, required substantial assistance from staff for daily activities. The resident's care plan included a restorative nursing program to prevent functional decline. However, the task documentation showed that restorative activities were not consistently performed. The DON and staff confirmed that the resident's restorative program was not properly documented, and the resident was not receiving the necessary restorative care. The facility's transition from paper to electronic records contributed to the lack of documentation and follow-through on restorative programs.
Inadequate Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient and competent staff to meet resident needs, particularly in bathroom care and timely response to call lights. Resident #31, who had severe cognitive impairment and required substantial assistance for toileting and personal hygiene, was observed in a wet and soiled state, indicating a lack of timely incontinence care. Staff interviews confirmed that the facility was often short-staffed, leading to delays in care and residents being found incontinent during rounds. Family members and staff reported that the evening shift was particularly problematic for staffing, with residents waiting at least 30 minutes for assistance and dietary staff having to deliver meals, causing further delays in care. During a Resident Council meeting, residents expressed concerns about the competency of some CNAs in providing bathroom care, particularly on the 2-10 shift. One resident reported waiting up to 2.5 hours for assistance after staff turned off the call light and did not return. Another resident was observed with visibly soiled clothes and a wheelchair cushion, further highlighting the issue of inadequate staffing and delayed care. Staff interviews corroborated these observations, with multiple staff members stating that the facility did not have enough staff to meet resident needs adequately. Additionally, an incident was observed where a CNA was found sleeping in a resident's room during their shift. The Administrator initially mistook the CNA for a visitor but later confirmed the staff member's identity and reported that the CNA was no longer employed at the facility. This incident further underscores the staffing issues and lack of oversight within the facility, contributing to the overall deficiency in providing adequate care to residents.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the long-term care ombudsman for a resident transfer to an acute care hospital. The resident was on an unpaid hospital leave due to making suicidal statements and was sent to the hospital. The facility's records showed that the resident was transferred back to the facility after a week. However, the Notice of Transfer Form to the ombudsman did not include this resident in the list of transfers for that month. The Social Services Director and Business Office Manager indicated that there were issues with the Electronic Health Record system, which may have caused the resident's transfer not to be reported correctly. The Social Services Director noted that the resident's census line had been revised, which affected the discharge report. The Administrator confirmed that the facility did not have a policy for ombudsman notification and that discharge information was sent to the ombudsman on a monthly basis.
Failure to Update Care Plans with Restorative Nursing Program
Penalty
Summary
The facility failed to update and revise the Care Plan to reflect therapy recommendations for a restorative activities program for three sampled residents. Resident #19, who had diagnoses of congestive heart failure, chronic kidney disease, and cancer, was independent with bed mobility, toileting, and transfers. Despite receiving occupational and physical therapy, the Care Plan lacked information regarding a restorative nursing program (RNP). The Director of Nursing (DON) confirmed that the resident's restorative activities program was not entered into the electronic health record (EHR) during the transition from paper documentation, leading to staff being unaware of the need for restorative exercises for the resident. Resident #28, who had diagnoses of stroke, spastic hemiplegia, and chronic pain syndrome, was dependent on staff for activities of daily living and had impaired range of motion in both upper and lower extremities. The Care Plan did not include information regarding a RNP, despite therapy recommendations for continued strengthening and range of motion exercises. The DON confirmed that the resident's restorative activities program was not entered into the EHR, resulting in no restorative documentation for the resident. The facility's policy on Restorative Nursing Services indicated that residents should receive restorative nursing care to promote optimal safety and independence, with goals and objectives outlined in the resident's care plan. However, due to the transition from paper to electronic documentation, the DON missed entering the restorative activities programs into the EHR, leading to a lack of restorative care for the residents. Staff interviews confirmed that therapy recommendations were provided to the DON, but the information was not properly documented in the care plans or EHR.
Failure to Transcribe and Implement Provider Orders
Penalty
Summary
The facility failed to properly transcribe and implement provider orders for a resident with moderate cognitive impairment, diabetes, and multiple skin integrity issues, including a Stage 3 pressure ulcer and a diabetic foot ulcer. The resident's care plan indicated a need for substantial assistance with bed mobility and noted a history of refusing care. An order for wound treatment to the resident's right buttocks was documented but failed to include a scheduled time for the treatment. This order was not transcribed into the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for March and April 2024, resulting in the treatment not being administered as required. Staff interviews revealed that the facility's triple-check process for transcribing orders was not followed correctly. The Registered Nurse (RN) and Licensed Practical Nurse (LPN) involved were unaware of the order, and the Assistant Director of Nursing (ADON) could not explain why the order was not transcribed. The Director of Nursing (DON) confirmed that the normal practice did not include verifying the scheduled time for orders. The facility's policy on medication orders required specifying the type, route, dosage, frequency, and strength of the medication, but it failed to direct the scheduling of medications, leading to the oversight in the resident's care.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure that a resident who desired routine dental care received the necessary services. Resident #15, who had intact cognition as indicated by a BIMS score of 15, was identified with likely cavities or broken natural teeth in the Significant Change MDS. Despite requesting dental services on multiple occasions, as noted in progress notes dated 9/1/2023 and 12/26/2023, there was no follow-up documentation. Resident #15 reported not having seen a dentist since admission and expressed willingness to leave the room for dental care, contradicting staff claims that she refused services. Staff T, responsible for dental scheduling, provided an undated document stating that Resident #15 refused dental care, which the resident denied. The Social Services Director also reported that the resident refused dental care due to not wanting to leave the room, but later mentioned that the resident's mother did not sign the application for dental care. The progress notes lacked any mention of follow-up, alternative treatment, or other dental care services provided to Resident #15.
Infection Control Deficiencies
Penalty
Summary
Facility staff failed to follow infection control practices, leading to the spread of infection within the facility. In one instance, a Certified Nursing Assistant (CNA) and a Certified Medication Aide (CMA) assisted a resident with severe cognitive impairment and incontinence without properly changing gloves or performing hand hygiene. The staff also failed to disinfect a urine-soiled recliner cushion, which the resident sat on after being cleaned. The Director of Nursing (DON) confirmed that gloves should be changed and hands sanitized between tasks, as per facility policy and CDC guidelines. In another instance, two CNAs conducted a transfer and incontinence care for a resident without performing hand hygiene. One CNA used contaminated gloves to clean the resident and then touched clean items and equipment without changing gloves or sanitizing hands. This CNA also failed to properly clean the resident's perineal area and subsequently touched various surfaces and another resident's wheelchair without sanitizing hands. The facility's hand hygiene policy mandates handwashing or sanitizing before and after resident contact and after glove removal. Additionally, a Certified Medication Aide (CMA) failed to perform hand hygiene while assisting multiple residents with meal setup. The CMA touched residents' utensils and food items without sanitizing hands between tasks. The facility's hand hygiene policy requires handwashing or sanitizing before and after assisting residents with meals. These lapses in infection control practices were observed and confirmed through staff interviews and facility policy reviews.
Failure to Administer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide education and administration of pneumococcal immunization for 28 residents identified as eligible, including two specific residents reviewed for the pneumonia vaccine. Resident #18, aged [AGE] years, had historical documentation of receiving Pneumovax 23 in 1999 but lacked documentation of consent, refusal, or receipt of the Prevnar 20 vaccine. Resident #47, aged [AGE] years, had consent from their POA for the pneumonia vaccine, but the clinical record lacked documentation of the vaccine's administration. An email from the corporate Director of Infection Prevention and Staff Development indicated that an audit identified 28 residents eligible for the Prevnar 20 vaccine, but the facility did not have documentation that these residents had been offered the newest version. The Infection Preventionist/DON confirmed the recent audit and noted that the Performance Improvement Plan aimed to ensure all consenting residents would be up to date on the Prevnar 20 vaccine within 14 days, with a target date of 4/1/24. However, the deficiency was noted as the facility failed to document the offering and administration of the vaccine to eligible residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Altoona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Vista Village | 1 mi | ★★★★★ | 0 | 0 |
| Parkridge Specialty Care | 3.6 mi | ★★★★★ | 18 | 0 |
| Valley View Village | 5.5 mi | ★★★★★ | 4 | 0 |
| Trinity Center At Luther Park | 6.6 mi | ★★★★★ | 17 | 1 |
| Azria Health Park Place | 7.4 mi | ★★★★★ | 25 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.