Alpine Meadow Rehabilitation and Nursing

Inspectors wroteBased on interview and record review, the facility did not ensure that the irregularities reported by the pharmacist to the attending physician and Medical Director (MD) were acted upon. In addition, the facility did not ensure the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. Specifically, for 5 out of 20 sampled residents, pharmacy recommendations were not acted upon by the MD and the MD did not document the identified irregularity and what action was taken in the resident's medical record. Resident identifiers: 10, 18, 19, 24, and 34.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically, for 1 out of 20 sampled residents, a resident was observed to have medication in their room and was not evaluated to determine if they were safe to self-administer that medication. Resident identifier: 1.

Inspectors wroteBased on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 20 sampled residents, a resident taking two types of diuretics had those diuretics administered at the same time when they should have been 30 minutes apart. Resident identifier: 10.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 20 sampled residents, staff did not wear personal protective equipment (PPE) during wound care for a resident that should have been on Enhanced Barrier Precautions (EBP). Resident identifier: 34.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were offered the influenza vaccine and that the medical record included documentation that the resident either received the vaccine or did not due to medical contraindications or refusal. Specifically, for 1 out of 5 sampled residents, there was no documentation of declination of the influenza vaccine. Resident identifier: 19.

Inspectors wroteBased on interview and record review, the facility did not ensure residents were offered the Coronavirus disease 2019 (COVID-19) vaccines. Specifically, for 1 out of 5 sampled residents, no documentation was located to demonstrate how the resident accepted or refused the COVID-19 vaccination. Resident identifiers: 19.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, hand hygiene was not performed when delivering lunch trays between multiple resident rooms.

Inspectors wroteBased on interview and record review it was determined, for 1 of 19 sampled residents, the facility must obtain laboratory services only when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. In addition, the facility must promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges. Specifically, resident's urinalysis (UA) results were not obtained from the lab and reported to the ordering physician. Resident identifier: 6.

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 of 12 sampled residents were free of significant medication errors. Specifically, three residents were not administered insulin at the correct time per the physician orders. Resident identifiers: 2, 4, and 10.

Inspectors wroteBased on interview and record review, it was determined for 2 of 12 sampled residents that the facility did not ensure that the residents were free from abuse. Specifically, two residents reported that a Certified Nurse Assistant (CNA) inappropriately touched them on their genitals. Resident identifiers: 1 and 11.

Inspectors wroteBased on interview and record review, it was determined for 1 of 12 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency (SSA). Specifically, a sexual abuse allegation was reported to the SSA. Resident identifier: 11.

Inspectors wroteBased on interview and record review, it was determined for 1 of 12 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, there was an allegation of abuse that was not thoroughly investigated. Resident identifier: 11.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including Coronavirus Disease 2019 (COVID-19). Specifically, during a COVID-19 outbreak the facility staff did not dispose of their used Personal Protective Equipment (PPE) correctly, staff did not wear eye protection when entering COVID positive resident rooms, meal trays were not bagged and identified when taken from COVID positive resident rooms and a symptomatic resident was not tested promptly for COVID-19 after staff were made aware. Resident identifier: 4 & 35.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 28 medication opportunities on 12/20/23, revealed seven medication errors which resulted in a 25% medication error rate. Specifically, for 3 out of 20 sampled residents, a resident was given an incorrect dose of an anticonvulsant, a resident received long acting insulin and corrective insulin for an elevated blood sugar late, and a resident with scheduled pain medication received them late. Resident identifier: 1, 20, 35.

Inspectors wroteBased on interview and record review it was determined for 4 of 20 sampled residents that the facility did not ensure that the residents were free from any significant medication errors. Specifically, a resident was given the incorrect dose of medication, a resident's insulin medication was not administered per the physician's ordered time, one residents pain medication was not administered per the physician's ordered time, and on residents anxiety medication was not administered timely causing the resident distress. Resident identifiers: 1, 20, 35, and 4.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerators and freezers were open to air.

Inspectors wroteBased on record review and interview it was determined, for 1 of 20 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). Specifically, a resident had an unwitnessed fall which resulted in a fracture and the SSA was not notified. Resident Identifier: 28. Findings Included: Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of chronic respiratory failure, muscle weakness, acute pulmonary edema, heart failure, acute kidney failure, and cellulitis. Resident 28's medical record was reviewed on 12/20/23. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 20 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, the facility did not thoroughly investigate an unwitnessed fall that resulted in a fracture. Resident Identifier: 28. Findings Included: Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of chronic respiratory failure, muscle weakness, acute pulmonary edema, heart failure, acute kidney failure, and cellulitis. Resident 28's medical record was reviewed on 12/20/23. On 8/25/23, a Quarterly Minimum Data Set (MDS) documented Resident 28 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated resident 28 was severely cognitively impaired. [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 20 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, facility staff were not changing the oxygen tubing. Resident identifier: 1, 18.