Inspection Reports for
Altoona Nursing and Rehabilitation Center

Complaint #2639275-C was substantiated. Facility reported incident #2652318-I was substantiated. The investigation found multiple resident-to-resident altercations involving Resident #6 and Resident #7, with staff failing to prevent harm and properly document incidents.

The facility was found not to have met requirements related to freedom from abuse, neglect, and exploitation, specifically failing to prevent resident-to-resident abuse incidents involving Resident #6 and Resident #7. Additionally, the facility lacked sufficient nursing staff to respond timely to call lights and failed to complete incident reports for some resident altercations. Resident records were also incomplete regarding incident documentation.

The facility failed to maintain safe and comfortable temperature levels in one of two dining rooms, resulting in excessively high temperatures over a weekend. Additionally, the facility failed to properly prepare and administer medications as prescribed for two of three residents reviewed, leading to missed insulin doses and unavailable eye drops.

Complaints #127066-C, #129029-C, and #129628-C triggered the investigation. Complaints #127066-C, #129029-C, and #129628-C resulted in deficiencies.

The facility failed to maintain comfortable and safe temperature levels in one of two dining rooms, with temperatures reaching the high 80s to low 90s due to a malfunctioning air conditioning unit. Additionally, the facility failed to prepare or administer medications as prescribed for 2 of 3 residents reviewed, including missed insulin doses and unavailable eye drops.

The facility had multiple deficiencies including failure to ensure residents' dignity, inadequate environment and noise control, insufficient rehabilitative services, inadequate assistance with activities of daily living, unsafe transfer practices, improper smoking material security, poor infection control practices, insufficient nursing staff, and ineffective hospice medication coordination. Repeat deficiencies from prior surveys were noted.

The investigation was triggered by multiple complaints and facility reported incidents. Complaints #120762-C, #121569-C, and #121575-C were substantiated, as was Facility Reported Incident #121862-I.

The facility failed to provide adequate perineal care and bathing according to residents' needs, failed to provide restorative exercises as per care plans, did not maintain a safe environment for residents at elopement risk, and failed to secure medication and treatment carts properly.

Complaint #119171-C and #120061-C were substantiated.

The facility was found deficient in multiple areas including failure to promptly notify resident representatives of room changes, failure to maintain a safe, clean, and homelike environment, failure to notify the state ombudsman of resident transfers, inaccurate Minimum Data Set (MDS) assessments, failure to update care plans to reflect therapy recommendations, failure to properly transcribe and implement provider orders, insufficient nursing staff to meet resident needs, failure to provide routine dental services, failure to maintain kitchen freezer in satisfactory condition, failure to follow infection control practices, and failure to provide pneumococcal immunizations to eligible residents.

The facility was found deficient in multiple areas including failure to notify resident representatives of room changes, inadequate maintenance of a homelike environment, inaccurate resident assessments, failure to provide restorative nursing programs, insufficient staffing impacting resident care, failure to provide dental services, improper food storage conditions, lapses in infection control practices, and incomplete pneumococcal vaccination administration.

The complaint investigation substantiated multiple issues including failure to notify family of room changes, environmental concerns with odors and clutter, inaccurate resident assessments, lack of restorative care, and inadequate staffing leading to delayed resident care and unmet needs.

The facility failed to notify a resident's representative of a room change, maintain a clean and odor-free environment, accurately code resident assessments, provide restorative nursing activities, and ensure adequate staffing to meet resident needs. Observations and interviews confirmed issues with odor control, cluttered hallways, inaccurate MDS coding, lack of restorative care documentation, and delayed or insufficient resident care due to staffing shortages.

The facility failed to maintain resident dignity and privacy, properly provide perineal care, treat pressure ulcers, respond timely to call lights, reconcile narcotic counts, and follow infection control protocols including glove use. Environmental issues such as unclean walls and flooring were also noted.

The visit was complaint-related, triggered by multiple complaints and a facility reported incident. Substantiation status is not explicitly stated.

The facility failed to treat residents with dignity and respect, maintain a safe and clean environment, provide proper perineal care, adequately treat a pressure ulcer, answer call lights timely, reconcile narcotic counts, and follow infection control procedures including proper glove use.

The facility failed to treat residents with dignity during showering, maintain clean oxygen equipment, follow physician medication orders, provide proper fall assessments, and respond to resident call lights within professional standards. Multiple residents and staff interviews, observations, and record reviews confirmed these deficiencies.

Complaints #114490, #114548, #116061, and #116711 were substantiated following the investigation conducted from November 8 to November 28, 2023.

The facility failed to treat residents with dignity and respect during showering, maintain privacy, properly clean oxygen concentrators, follow physician orders for medication administration, conduct necessary assessments after falls, and respond timely to resident call lights. Multiple deficiencies were identified based on observations, clinical record reviews, staff and resident interviews, and resident council minutes.

The facility had multiple deficiencies including failure to provide dignity in catheter care, failure to coordinate dermatology appointments, failure to notify ombudsman of transfers, failure to refer residents for PASRR evaluations, improper PICC line care, failure to address significant weight gain, improper catheter care, inadequate respiratory care, incomplete dialysis assessments, lack of nurse aide performance reviews, medication errors including insulin pen misuse and IV infusion errors, expired vaccine storage issues, failure to timely submit veteran affairs eligibility, improper PPE use, and inadequate nurse aide training.

Complaints #108019, #108029, and #109251 were substantiated. Complaints #108270 and #109503 were not substantiated. Self-reported incidents #108270 and #109650 were substantiated.

The facility was found deficient in multiple areas including resident rights, dignity in catheter care, reasonable accommodations, notice requirements before transfer/discharge, PASRR coordination, professional standards in care, quality of care, dialysis monitoring, medication error rates, medication administration, drug storage, infection prevention and control, bowel/bladder incontinence, respiratory care, nurse aide performance reviews, licensure compliance, and in-service training for nurse aides. The facility submitted a plan of correction with compliance dates of February 9, 2023.

The investigation included complaints #103681-C, #104018-C, #104039-C, #104926-C, #104980-C, #106617-C and facility-reported incidents #102956-I, #106323-M, #106524-I, and #106805-I. Some complaints were substantiated (e.g., #104018-C, #104039-C, #102956-I), while others were not. The facility failed to report allegations of abuse timely as required by state law.

The facility failed to report allegations of abuse in a timely manner and did not follow physician orders for some residents. Deficiencies were found related to abuse reporting, comprehensive care plans, medication administration, pharmacy services, and food safety standards.

Multiple complaints were investigated, with most substantiated except complaint #100341. Facility Reported Incidents #102811 and #102381 were substantiated. The investigation included resident and staff interviews, clinical record reviews, and policy reviews.

The facility was found to have multiple deficiencies including failure to maintain resident dignity and respect, inadequate coordination of care and services, unsafe medication administration practices, and insufficient infection control measures. Several residents experienced neglect and improper care, and staff failed to follow policies and procedures.

Complaint #97849-C was substantiated. Facility Reported Incident #97422-1 was substantiated.

The facility was found to have multiple deficiencies including failure to maintain resident privacy and confidentiality, failure to develop and implement abuse/neglect policies, failure to complete criminal background checks for staff, failure to coordinate PASARR assessments, failure to develop baseline and comprehensive care plans, failure to provide adequate ADL care, failure to ensure CPR certification for staff, failure to maintain infection control, and failure to provide adequate supervision and accident prevention.

The complaint investigation was triggered by complaints investigated under IA00094975, IA00096117, IA00096129, IA00095430, and IA00096267. The Administrator was notified of an immediate jeopardy (IJ) related to the unsupervised steam table on 4/5/21 at 6:30 pm. The IJ was removed on 4/6/21 after corrective actions were implemented.

The facility failed to prevent resident access to a steam table turned on to the highest setting, posing a burn hazard to cognitively impaired residents. Additionally, the facility failed to secure a cabinet containing resident smoking materials, which were left unlocked and accessible.

Complaints #94975-C, #86117-C, #86129-A, and #95430 were investigated. Complaint #94975-C was substantiated without a deficiency. Complaint #86117-C was substantiated. The investigation focused on abuse and neglect allegations involving Resident #5 and staff members.

The facility was found to have substantiated complaints of resident abuse and neglect involving staff behavior toward residents, including inappropriate touching and verbal abuse. The facility failed to provide mandatory abuse training for staff and failed to report allegations of abuse timely. Resident #5 was involved in multiple incidents of inappropriate behavior and staff responses were inadequate.

Complaint #94041-C was not substantiated. Complaints #93877, #94429-C, #94684-C, #94665-C, #94686-C, #94673-C, #94674-C, #94675-C, #94678-C, #94680-C, #94681-C, #94882-C, #94683-C, #94684-C, #94685-C, #94688-C, #94687-C, #94689-C, #94690-C, #94894-C, #94695-C, #94001-C, #94929-C, and #94971-C were substantiated. Facility Report Incident #94841-I was substantiated.

The facility was found to have deficiencies related to quality of care, medication errors, and infection prevention and control. Specific issues included failure to provide treatment and care according to professional standards for Resident #12, significant medication errors affecting Resident #3, and inadequate infection control practices during a COVID-19 outbreak.