Altoona Center For Nursing Care

F-F919.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(b)(1)(e)(1) Management.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 22 395985 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395985 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Midtown Oaks Health & Rehab Center 1020 Green Avenue Altoona, PA 16601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38012

Residents Affected - Some Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 22 residents reviewed (Resident 2).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 18, 2024, indicated that the resident was cognitively impaired, exhibited physical behavior symptoms, wandered daily, required assistance with personal care needs, and had diagnoses that included dementia. The resident had an MDS assessment, dated May 5, 2024, indicating that

the resident was discharged with return anticipated.

A review of the census record for Resident 2 revealed that he was discharged on [DATE REDACTED].

A nursing note for Resident 2, dated May 5, 2024, at 10:00 p.m. revealed that the resident's physical and verbal aggression had increased, the physician was notified, and Resident 2 was transferred to the hospital.

A nursing note for Resident 2, dated May 14, 2024, at 3:33 p.m. revealed that the resident remained out of

the facility related to an increase in aggressive behaviors that compromised the safety of the facility and that

the interdisciplinary team would review the resident's plan of care upon his return to the facility. There was no further documentation in the resident's clinical record to indicate the discharge plan for Resident 2.

Interview with the Nursing Home Administrator on July 2, 2024, at 2:59 p.m. revealed that facility had communicated with the hospital regarding Resident 2's return to the facility and eventual discharge from the facility; however, there was no documentation in Resident 2's clinical record indicating that the facility was communicating with the hospital or that the resident had discharge plans. The Nursing Home Administrator confirmed that the resident's clinical record was incomplete.

28 Pa. Code 211.5(f) Clinical Records.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 395985 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395985 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Midtown Oaks Health & Rehab Center 1020 Green Avenue Altoona, PA 16601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Immediate 38012 jeopardy to resident health or safety Based on review of policy and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that the call bell system was adequately equipped to allow Residents Affected - Some residents to call for staff assistance, by failing to ensure that the call bell system was working. This failure put 15 of 22 residents reviewed who need to utilize their call bell for staff assistance in an Immediate Jeopardy situation.

Findings include:

The facility's policy regarding resident communication system and call lights, dated April 30, 2024, revealed that it was the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath area. The facility will respond to resident needs and requests.

A review of Resident Council meeting minutes, dated April 2024, May 2024, and June 2024, revealed that

the residents were concerned about the call bell wait time and that they felt the wait time for a call bell to be answered was excessive, sometimes up to an hour.

Observations on July 2, 2024, from 10:13 a.m. to 10:30 a.m. revealed that the residents' call lights were recessed in the ceiling above their room and not visible from a couple of rooms away. There was no sound activated when a call bell was pressed.

Interview with Licensed Practical Nurse 5 on July 2, 2024, at 10:23 a.m. revealed that she relies on the nurse aides to answer the call bells, and that she will answer them if she knows they are on. She said that they do not make a sound anywhere. She did not have any device on her that alerted her if a call bell was pressed.

Interview with Registered Nurse 6 on July 2, 2024, at 10:23 a.m. revealed that she is not sure where the call bells sound to. She said that the nurse aides are responsible for answering the call bells and that she does try to help. She is new to the facility and not aware of any device that the nursing staff carries to alert them of any call bell.

Interview with Nurse Aide 4 on July 2, 2024, at 10:30 a.m. revealed that she tries to watch for the lights above the resident's door ways to indicate that the resident's call bell is on. She said there is no sound, and

she does not know of any device that she should carry that would alert her that the call bell is on. She said

the resident's have complained to her that they have waited too long, but she does not know how long their call bells were actually on because they do not make a sound.

Interview with Nurse Aide 7 on July 2, 2024, at 10:38 a.m. revealed that the call bells do not make a sound anywhere in the hall or at the nurse's station, and she did not have any device that alerted her that the resident's call bell was on.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 395985 Department of Health & Human Services Printed: 09/19/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395985 B. Wing 07/03/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Midtown Oaks Health & Rehab Center 1020 Green Avenue Altoona, PA 16601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Interview with the Nursing Home Administrator (NHA) on July 2, 2024, at 2:53 p.m. revealed that, in the past,

the staff were supposed to carry a pager that would alert them when a resident's call bell was pressed. She Level of Harm - Immediate stated that, at some point, the staff stopped charging the pagers and stopped carrying them. She stated that jeopardy to resident health or she purchased mini kiosks for the staff to be able to sit in the hallways and do their charting so they could safety visualize the recessed light above the resident's door when the resident would press their call bell. She was not sure why the staff that were interviewed were not aware that they were to be charting in the hallways and Residents Affected - Some watching for call bells to light up. She said she was aware that the call bells were not sounding at the nurse's station because the current system did not function that way. She said that there was a system where the staff wore a pager and it would alert them when a call bell was pressed and that the nurse aide would be alerted first, and then the nurses would be alerted if the nurse aides did not answer the bell in an allotted time. However, she stated the pagers were misplaced or not charged and the staff were not carrying them.

On July 3, 2024, at 10:46 a.m. the NHA was informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses, licensed practical nurses, and nurse aides not knowing when

the residents were calling for assistance. The NHA was provided with the IJ template at 10:46 a.m.

The facility submitted and implemented an immediate plan to ensure resident safety by providing each resident with a tap bell or a cow bell that, when sounded, staff could audibly hear. The facility also placed hall monitors in each of the four halls so that the residents' bells could be heard and staff would be alerted as to who needed assistance. Staff were educated regarding the temporary system. The facility was able to locate pagers, replace the batteries, and pass them out to staff for use. The pagers will be signed in and out each shift, and maintenance will replace the batteries once a month.

The Immediate Jeopardy was lifted on July 3, 2024, at 4:36 p.m. when it was confirmed that each resident had a tap bell or a cow bell that was audible to staff; that over 90 percent of the nursing staff received education regarding the temporary call bell system, with the remaining staff scheduled to receive the education prior to the start of their next shift; and that the facility contacted a contractor to purchase a new call bell system or change the current one to a system that makes sounds at a central location.

28 Pa. Code 207.2(a) Administrator's Responsibility.

28 Pa. Code 211.12(d)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 395985