Allegany Health Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Allegany Health Nursing and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF678Jan 24, 2025

  Based on reviews of a facility-reported incident, a closed medical record and all pertinent information and staff interview, it was determined that the facility staff failed to identify a newly admitted Resident who was admitted without clear physician's order for end-of-life care and failed to follow the facility policy to initiate Cardiopulmonary Resuscitation (CPR). This was evident for 1 (Resident #902) of 11 facility-reported incidents reviewed during an annual recertification survey. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. […]

• Actual harm, isolatedF689Jan 24, 2025

  Based on reviews of a facility-reported incident, a closed medical record and all pertinent information, and staff interviews, it was determined the facility staff failed to provide adequate supervision and follow the resident's plan of care to: 1) prevent a fractured humerus during a transfer, and 2) to prevent a cognitively and functionally impaired resident from sliding out of bed onto the floor and receiving bilateral fractured hips. This was evident for 2 (Residents #909, #906) out of 11 facility-reported incidents resulting in harm to both residents reviewed during the survey. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. […]

• No harm, potential for more than minimal, isolatedF641Apr 3, 2026

  Based on medical record review and interview it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's current status. This was found to be evident for one (Resident #28) out of three residents reviewed for pressure ulcers.The findings include:The Minimum Date Set (MDS) is a complete assessment of the Resident that provides the facility with the information needed to develop a care plan, deliver the appropriate care and services, and modify the care plan based on the Resident's status. Review of Resident #28's medical record revealed a wound specialist note, dated 3/11/26, that documented the presence of an unstageable deep tissue injury (DTI) on the resident's right lateral foot. […]

• No harm, potential for more than minimal, isolatedF657Apr 3, 2026

  Based on interview and medical record review it was determined that the facility failed to ensure an interdisciplinary care plan meeting was held to review and revise the resident's care plan after the completion of a Minimum Data Set (MDS) assessment. This was found to be evident for one (Resident #6) out of two resident's reviewed for urinary catheter use.The findings include: Care Conferences, also known as care plan meetings, are interdisciplinary team meetings that are to occur following the completion of Minimum Data Set (MDS) assessments. The MDS is a complete assessment of the Resident that provides the facility with the information needed to develop a care plan, deliver the appropriate care and services, and modify the care plan based on the Resident's status. […]

• No harm, potential for more than minimal, isolatedF679Apr 3, 2026

  Based on medical record review, observation and interview it was determined that the facility failed to ensure the provision of activities to meet the needs of residents with dementia. This was found to be evident for 2 (Resident #122 and #9) out of 5 residents reviewed for dementia care.The findings include1.Review of Resident 122's medical record revealed the resident has resided at the facility for more than 6 months, was legally blind and had dementia. The resident resided on the secured unit, in which a code was required to gain access to the elevator to leave the unit. On 3/30/26 at 11:09 AM Resident #122 was observed ambulating in the hallway, dressed for the day. […]