Alta Heights Post Acute

Inspectors wroteBased on review of the Resident Assessment Instrument Manual Version 1.20.1, medical record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for 2 of 18 (Resident #62 and #74) residents reviewed for MDS discrepancies.

Inspectors wroteBased on the facility policy review, observations and interviews, the facility failed to properly label, date and store food items in the kitchen and failed to properly store, label and date personal resident food items in the 300 Hall nourishment room.

Inspectors wroteBased on policy review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 3 nurses (Licensed Practical Nurse (LPN O, LPN W, LPN X) failed to clean reusable equipment before and after use and failed to use protective barriers, and when 1 of 3 nurses (LPN X) failed to wear Personal Protective Equipment (PPE) in enhanced barrier precaution rooms.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to provide and maintain a safe and sanitary environment for 11 of 48 occupied rooms (Resident #5, #9, #29, #36, #40, #44, #51, #65, #20 and #67's room, #68 and #27's room, and #72, and #73's room) when there was a broken/missing piece on the window blind, a sharp screw exposed on the closet door, there were holes in the wall, missing hooks from the privacy curtain, the air conditioner's front panel and filter was off, a cable cord box was not attached to the wall, there were bulging and missing pieces from the over tables, there were missing laminate pieces from the dresser and nightstands, plaster was peeling from the wall, uncovered corner pieces on the wall, a broken bed with no mattress stored in a resident's room, and when there were strong malodorous odors in residents' rooms.

Inspectors wroteBased on policy review, interview, and observation, the facility failed to provide reasonable accommodations of needs for water temperature when bathing for 3 of 14 sampled residents (Resident #24, #28, and #64) interviewed for activities of daily living.

Inspectors wroteBased on the facility policy review, medical record review, observation and interview the facility failed to provide privacy for 1 of 28 (Resident #28) sampled residents reviewed.

Inspectors wroteBased on policy review, medical record review, facility investigation, observation, and interview, the facility failed to ensure an allegation of abuse was reported for 1 of 6 (Resident #27) sampled residents reviewed for allegations of abuse and neglect.

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to revise comprehensive care plans for 2 of 28 (Resident #3 and #64) sample residents reviewed.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services related to activities of daily living (ADLs) for 1 of 3 (Resident #29) sampled residents for ADLs.

Inspectors wroteBased on facility policy review, medical record review, facility investigation, and interview, the facility failed to provide adequate supervision and assistance to prevent an elopement from the facility for 1 of 3 residents (Resident #80) reviewed for wandering. The facility failed to provide adequate supervision and assistive devices when Resident #1 eloped from the facility on 10/29/2024 at 9:40 AM, resulting in a fall with minor injuries. The Findings Include: 1. [...]

Inspectors wroteBased on policy review, medical record review, and interview the facility failed to ensure a resident's medication regimen was free of unnecessary medications when the facility failed to ensure monitoring related to the use of an anticoagulant (blood thinner) for 1 of 5 residents (Resident #39) sampled for unnecessary meds.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a medication administration error rate of less than 5% (percent) when 2 of 5 nurses (Licensed Practical Nurse (LPN) W and X) failed to properly administer medications for 2 of 5 sampled residents (Resident #73 and #129) observed during medication administration. This resulted in a medication administration error rate of 12.5 % [percent] when 3 errors occurred out of 24 opportunities.

Inspectors wroteBased on policy review, observation, and interview the facility failed to ensure medications were properly stored when 1 of 1 Licensed Practical Nurse (LPN DD) left 1 of 7 med storage areas unlocked and unattended, when medications were left on an over the bed table in 1 of 48 occupied rooms, and when 2 of 3 nurses Licensed Practical Nurse (LPN O and LPN X) left meds unattended and out of sight during medication administration.

Inspectors wroteBased on facility policy review, medical record review and interview, the facility failed to develop and implement a baseline care plan to address resident safety needs for 7 (#11, #25, #60, #66, #69, #75, and #276) of 24 residents who were identified on admission to be at risk for falls. The facility's noncompliance placed Resident #276 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) when the resident sustained a femur fracture as the result of a fall and also had the potential to place Residents #11, #25, #60, #66, #69, and #75 in Immediate Jeopardy. The Administrator was informed of the Immediate Jeopardy (IJ) on 11/18/19 at 1:20 PM in her office. F-655, and F-689 were cited at a scope and severity of J. [...]

Inspectors wroteBased on facility policy review, medical record review, facility investigation and interviews, the facility failed to provide adequate supervision to prevent falls for 2 (#276, #39) of 24 residents who were assessed at risk for falls. The facility's noncompliance placed Resident #276 and #39 in Immediate Jeopardy (IJ) When Resident #276 sustained a femur fracture from a fall and resident #39 sustained skin tears to her head and forearm from a fall. The Administrator was informed of the Immediate Jeopardy (IJ) on 11/18/19 at 1:20 PM in her office. F-655, and F-689 were cited at a scope and severity of J. The facility was cited F-689 J which was Substandard Quality of Care. An extended survey was conducted from 11/18/19 to 11/19/19. The Immediate Jeopardy was effective from 9/23/19 through 11/18/19. [...]

Inspectors wroteBased on facility policy review, medical record review, observation and interview, the facility failed to provide a dignified dining experience for 1 (#71) of 6 residents who required assistance during mealtime.

Inspectors wroteBased on facility policy review, medical record review and interview the facility failed to develop a person-centered care plan for 2 (#69, and #71) of 38 residents reviewed for care plans.

Inspectors wroteBased on facility policy review, medical record review, observation and interview the facility failed to revise the comprehensive care plan for 2 (#27 and #43) of 38 residents reviewed for care plans.

Inspectors wroteBased on the Facility policy review, observation and interview, the facility failed to properly store medications in 2 of 5 medication carts observed.