Alta Rehab at Fairmont

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that one dependent resident (R10) received timely incontinence care. The facility also failed to timely provide activities of daily living (ADL) care to ensure that two residents (R1 and R3) did not have excessive facial hair and/ or debris in beard. These failures have affected three (R1, R3, R10) of four residents reviewed for quality of care which resulted in R10 experiencing psychosocial harm becoming tearful and expressing her feelings of upset and frustration for delayed incontinence care.

Inspectors wroteBased on interviews and record review, the facility has failed to provide restorative services to two contracted residents (R8 and R9). This failure has affected two of four residents reviewed for restorative services.

Inspectors wroteBased on interview and record review, the facility failed to follow physician order for bi-level positive airway pressure (BIPAP) use and ensure continuous positive airway pressure (CPAP) / BIPAP device (mask, tubing and exhalation port) were cleaned daily. These failures affected five (R1, R2, R3, R4 and R6) of six residents reviewed for Improper nursing care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure ordered scheduled medications were administered for one resident (R2). This failure affected one resident out of three residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow food item labeling practices to ensure there are no outdated food items in the kitchen for resident consumption. This failure has the potential to effect 141 residents that receive food from the kitchen.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to (a) properly date opened multi-dose insulin for three (R7, R126 and R137) residents, and (b) ensure multi-dose eye drops were properly stored at appropriate temperature for two (R35 and R67) from 4 of 8 medication carts and 1 of 2 medication rooms inspected for medication storage and labeling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a) perform hand hygiene before and after having direct contact with residents and ensure necessary equipment are maintained to carry out an effective infection control program for five (R14, R55, R58, R140 and R147) of five residents reviewed for infection control b) ensure that its staff follow proper personal protective equipment (PPE) protocols for one (R99) out of five residents reviewed in a sample of 29.

Inspectors wroteBased on observation, interview and records review, the facility failed to protect privacy for one (R101) resident of six residents reviewed in a sample of 29. R101's current face sheet documents R101's diagnosis to include but not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, alcoholic cirrhosis of liver without ascites, adult failure to thrive, dysphagia, oropharyngeal phase. R101's Brief Interview for Mental Status (BIMS) dated 08/22/2025 documents R101 has BIMS score of 6/15, indicating R1 has severe cognitive disability. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physician order, develop plan of care and determine if self-administration of medication was appropriate for one (R52) of one resident observed with medication at bed side table in a sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS) assessment using the Centers for Medicare Medicaid (CMS) specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for 1 (R80) of 1 resident reviewed for quarterly resident assessment in a sample of 29. On 09/11/2025 at 12:56PM, V22 (Minimum Data Set (MDS)/Care Plan Coordinator) stated the purpose of the MDS is to describe the resident and give a picture of the care a resident will receive. V22 stated the MDS is submitted to CMS (Centers of Medicare Medicaid) every quarter (every 92 days) or more frequently if the resident has experienced significant change. V22 stated R80's ARD (Assessment Reference Date) was completed late and further stated assessment should be completed within 14 days from the ARD. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to initiate a person-centered care plan with appropriate interventions for one resident (R94) of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly position one resident (R24) of 29 reviewed for activities of daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure feeding assistance was provided to a resident on aspiration precaution. This failure affected one (R83) resident reviewed for activities of daily living (ADL) care out of 29 residents in the final sample. Findings Include: On 9/9/25 at 12:18 PM, R83's in bed eating lunch independently with head of bed up to 90 degrees. R83's meal ticket reads in part: 1200 fluid restriction with 1:1 [one-to-one] feeding. Surveyor observed a signage posted on R83's closet documents in part: Feeding-Aspiration precautions. Patient requires 1:1 feeding. Small teaspoon presentation at a time. Do not provide secondary bites until patient swallows and clears mouth. Do not leave patient alone with tray. On 9/9/25 at 12:28 PM, R83 was observed still eating lunch unassisted in her room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure to (a) measure upper circumference and exterior catheter length, (b) change midline dressing timely, (c) provide maintenance flush, and (d) develop comprehensive care plan of midline use for 1 (R12) resident. The facility also failed to ensure physician's order was followed for a resident (R1) with aspiration precaution. These failures affected two (R1, R12) residents out of 29 residents in the final sample reviewed for quality of care. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall interventions for two residents (R24, R151) of 29 reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the water ordered for flushes is administered per doctor orders for one (R99) out of five residents reviewed in a total sample of 29. This failure places residents at risk to be provided with inappropriate care and services to meet the resident's physical, mental and/or psychosocial needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident (R83) received the correct oxygen flow rate as ordered by the physician and to ensure nasal cannula tubing was applied to a resident receiving oxygen for 1 (R1) of 2 residents reviewed for respiratory care in a final sample of 29. Findings Include:On 9/9/25 at 10:43 AM, R1 was lying in bed alert and awake noted with bouts of confusion. R1's oxygen (O2) concentrator was turned on and flow rate set to 2 liters per minute (lpm). R1's nasal cannula (nc) tubing was wrapped around her left side rail; the nasal prong was on the floor and was not applied in her nose. R1 was not in distress. On 9/9/25 at 10:59 AM, V5 (Certified Nursing Assistant) entered R1's room and applied the nasal cannula tubing for R1. V5 stated that it should have been in her nose. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the risk versus benefits of using side rails and review them with the resident prior to use and failed to implement person-centered comprehensive care plan addressing the use of the side rails. These failures affected two (R4, R52) out of three residents reviewed for side rails in a final sample of 29. Findings Include: On 9/9/25 at 11:47 AM, R4 was sitting on the side of the bed and noted with two upper half side rails up. R4 stated she gets out of bed by herself and uses a wheelchair to get around. On 9/10/2025 at 11:37 AM, R4 was sleeping in bed and noted with two half upper side rails up. On 9/10/25 at 10:43 AM, V22 (MDS Coordinator) stated that the purpose of the care plan is to notify the staff how to provide care for the residents. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a medication error rate of less than 5% for three (R55, R58 and R147) of five residents with 12 errors for 35 medication administration opportunities. This resulted in a medication error rate of 34.29%.

Inspectors wroteBased on interview and record review, the facility failed to ensure Discharge Instruction was completed and provided to a resident upon discharge to ensure a safe and effective transition of care. This failure affected 1 (R5) resident reviewed for discharge requirement in the total sample of 12 residents.

Inspectors wroteBased on interview, and record reviewed the facility failed to assure that a resident (R1) with a pressure ulcer received necessary treatment and services for prescribed wound care as ordered by the physician in order to promote healing. These failures affected one resident (R1) reviewed for wound care in a total sample of four residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident (R1) remained free from physical abuse from another resident (R2) reviewed for physical abuse in the sample of 4. This failure affected R1 who was pushed down on the bed by R2.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff/visitors are aware of required PPE (Personal Protective Equipment) prior to entering isolation rooms, failed to ensure that PPE is properly disposed of, and failed to ensure that required isolation signs were posted for two of four residents (R1, R4) reviewed for infection control. These failures have the potential to affect 153 residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to address reported pest/rodent sightings and failed to maintain an effective pest control program for three of three residents (R1, R2, R3) reviewed for pests/rodents. These failures have the potential to affect 153 residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that the building was maintained, and failed to provide a clean, comfortable homelike environment for three of three residents (R1, R2, R3) reviewed for resident rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the residents' rights to be free from physical abuse. These failures affected 2 residents (R1 and R2) resulting in R2 grabbing R1's thumb causing R1 pain; and R1 grabbing R2 in the chest causing multiple scratches and pain to R2.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision, and an environment that is free from accidents and hazards for one (R1) of five residents reviewed in a total sample of four residents. This deficiency resulted in R1 falling from bed and sustaining a right femur fracture and swelling to the forehand.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to update family on their grievance regarding insulin ordering issues for 1 (R4) out of three residents reviewed for grievance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent development of deep tissue injuries (DTIs) for one of three residents (R6) reviewed for pressure ulcers.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that (R2's) monthly weights were documented, failed to ensure that resident dietary preferences are included on nutritional assessments and failed to ensure that two of five residents (R1, R2) in the sample remained free from significant weight loss. These failures resulted in R2 sustaining 7.1% weight loss in 1 month and R1 sustaining 11.6% weight loss within 6 months.

Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure that the staff are aware of resident equipment needs, failed to ensure that [NAME]'s include mobility devices, and failed to ensure that required devices were provided to two of three residents (R2, R5) reviewed for transfer assistance. These failures have the potential to affect 153 residents.

Inspectors wroteBased upon record review and interview the facility failed to develop a comprehensive care plan including potential for abuse/neglect for four of five residents (R2, R3, R4, R5) in the sample. This failure has the potential to affect 153 residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that the menu was followed. These failures affected 155 residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that required infection control signs are posted, failed to ensure that the infection log includes required symptom, the date of onset and/or date of prophylactic treatment, failed to follow physician orders, failed to ensure that skin integrity impairments are documented, failed to report ongoing rash/itching to the Physician/Nurse Practitioner, failed to provide treatment timely, and/or failed to ensure that skin scrapings were obtained for two of four residents (R3, R5) reviewed for scabies. These failures have the potential to affect 153 residents.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that two of three residents (R2, R5) reviewed for transfer assistance remain free from involuntary seclusion.

Inspectors wroteBased upon record review and interview the facility failed to ensure that scheduling and/or colonoscopy policies/procedures are available, failed to follow physician orders, failed to ensure that transportation was arranged prior to colonoscopy, failed to ensure that scheduled appointments/transportation records are retained, failed to receive required bowel prep medication, NPO (Nothing by Mouth) and/or clear liquid diet orders prior to scheduled colonoscopy, failed to provide timely services, and failed to ensure that diagnostic results were received for one of three residents (R1) reviewed for significant weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Daily Nursing Staffing was posted daily and failed to ensure previous Daily Nursing Staffing were maintained. These failures have the potential to affect all 160 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents' food items in the facility kitchen are dated when received and when opened; and failed to discard expired food items. These failures have the potential to affect all 157 residents receiving an oral diet in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the dumpster was closed. These failures have the potential to affect all 160 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tanks were properly stored for one resident (R3) and failed to discard a lancet for one resident (R83). These failures affected 2 (R3 and R83) reviewed for hazards and have the potential to affect all 20 residents on the Team 2A unit and 14 residents on the Team 4 unit.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the nebulizer tubing was changed weekly per facility policy, the nasal cannula was contained when not in use by the resident, and the nasal cannula and humidifier canister were labeled/dated. These failures affected two residents from Team A (R123 and R98), one resident from Team 3 (R79), and one resident from Team 4 (R32); out of a sample of 65 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired medication from the medication cart, failed to discard expired medication from the medication supply room and failed to ensure medication carts were free of loose pills. These failures affected one resident (R54) for medication and storage labeling and have the potential to affect all sixty-eight residents assigned to carts Team 2A, Team 3, and Team 5. This failure also has the potential to affect all ninety-six-residents assigned to the medication storage room on Team 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly log refrigerator temperatures for resident's personal refrigerators for 10 residents (R29, R46, R55, R62, R79, R107, R120, R141, R401, & R402) and failed to adequately maintain the freezer for resident's personal refrigerators for 2 residents (R24 & R99). These failures have the potential to affect all 12 residents reviewed for safety of personal food items, in a total sample of 65 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update a resident's (R89) isolation status; failed to ensure staff did not bring the clean linen cart inside the resident's (R21) room; failed to wear Personal Protective Equipment (PPE) for a resident (R12) with Enhanced Barrier Precautions (EBP); and failed to maintain infection control practices in effort to prevent the spread of microorganisms for a resident (R79). These failures affected four residents (R12, R21, R79, and R89) and has the potential to affect all 20 residents on Team 2A unit and all 17 residents on Team 3 unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a handrail was firmly secured to the wall in an effort to prevent falls. This failure has the potential to affect all residents in Unit 2B.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure indwelling catheter drainage bags were covered to maintain the resident's dignity. This failure has affected 2 residents (R27 and R109) reviewed for catheter care in a total sample of 65 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure electronic health records were kept in a private manner. This failure has the potential to affect 1 resident (R102) in a sample of 65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for 2 (R96 and R108) residents reviewed for homelike environment in the total sample of 65 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a new Pre-admission Screen and Resident Review (PASARR) assessment was completed when a new diagnosis of schizoaffective disorder was identified. This failure affects 1 resident (R49) in a sample of 65.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL (Activity of Daily Living) care for two residents (R45, R74) to maintain personal hygiene. This failure has the potential to affect the sample size of 65.

Inspectors wroteBased on interview and record review the facility failed to ensure that resident's medications are administered as ordered by the physician. This failure affected two residents on Team 4 (R32 and R81) of 65 residents reviewed for quality of care and administration of prescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment used for catheter care was discarded after use in an effort to prevent contamination. This failure affected 1 (R21) resident reviewed for indwelling catheter care in the total sample of 65 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to be free of medication error rate of 5% or more. There were a total of 3 medication errors out of 25 opportunities. The medication error rate is 12% and affects one resident R99.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse to the State Agency, failed to inform local law enforcement when an allegation of physical abuse involved physical injury, and failed to implement their policy and procedure in reporting injury of unknown origin. These failures affected 1 (R2) resident reviewed for reporting of physical abuse and injury of unknown origin in the total sample of 8 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff was appropriately transferring a resident (R5) and failed to ensure staff appropriately provide supervision during incontinence care to a dependent resident (R4). These failures affected 2 (R4 and R5) residents reviewed for supervision in the total number of 8 residents:

Inspectors wroteBased on observations, interviews, and review of records the facility failed to follow pest control policy and establish effective pest control program in conducting pest control prevention on a regular and as needed basis. These failures have the potential to affect all 153 residents in maintaining to be free from pest concerns.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to maintain resident rights to privacy and dignity per their policy for 4 out of 4 residents (R6, R7, R8, R9) with common restroom that is able to access from female to male occupancy and vice-versa without assessment and care plan. These failures have the potential to affect 4 residents (R6, R7, R8, R9) in their right to privacy and dignity.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to follow proper transfer procedure based on resident assessment by transferring resident done by a single staff that needs 2-person extensive assist. Facility also failed to update plan of care on transfers per assessment. These failures apply to 1 out of 3 residents (R2). And have the potential to affect 1 resident (R2) on safely transferring and prevention of accidents.

Inspectors wroteBased on interviews, observations, and review of records the facility failed on administering insulin as ordered by physician in accordance with resident five (5) rights during medication administration for 1 out of 3 residents (R1) reviewed for pharmaceutical services. These failures have the potential to affect 1 resident (R1) in depriving the benefits of insulin to manage his medical diagnosis of diabetes mellitus.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to maintain privacy curtain to provide visual privacy to a room that has no restroom for 1 out 1 resident (R5) reviewed for facility environment. These failures has the potential to affect 1 resident (R5) in maintaining visual privacy inside the room.

Inspectors wroteBased on observations and interview the facility failed to provide safe, sanitary, and comfortable environment in a room that has prior incident of electrical burning due to urine contact with electricity for 1 out of 1 resident (R15) reviewed for physical structure. These failures has the tendency to reoccur and to affect 1 resident (R15) when left without proper precautions.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to provide sufficient supplies of incontinent wipes and gowns for 120 out of 165 residents. These 120 residents were identified by facility as incontinent and needs incontinent care. These failures have the potential to affect 120 residents in receiving proper hygiene and incontinence care due to lack of supplies of incontinent wipes and gowns.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all 148 residents who consume food prepared in the facility.

Inspectors wroteBased on observation , interview and document review the facility failed to maintain an effective pest control program so that the facility is free of pests. This deficient practice affects all 154 residents in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess residents' ability to safely self-administer medications and/or treatments. This failure has affected 3 (R70, R83, and R118) residents reviewed for self-administration of medications in the total sample of 48 residents and has the potential to affect all 40 residents residing in Team Unit 5 and Team Unit 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remains free of hazards for four residents (R52, R109, R121 and R126). This failure has the potential to affect all 29 residents on the Team 3 unit and all 17 residents on the Team 5 unit.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the treatment cart was kept locked when not in use by staff. This failure has the potential to affect all 48 residents in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that an oxygen tubing was changed in a timely manner for one resident (R96), who depends on supplemental oxygen, from a sample of 48 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a temperature thermometer for two residents (R52 and R62) refrigerators; and failed to properly log refrigerator temperatures for four residents (R32, R52, R55, and R62). These failures have the potential to affect all 48 residents in the sample.

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly. This deficient practice has the potential to affect all 154 residents in the facility. On 07/17/23 at 10:30AM facility outside dumpster area observed with torn open large garbage bags containing spoiled food piled behind dumpster. The ground surface was heavily soiled with liquid food spill and debris. One of the 3 dumpsters was missing the lids. Heavy fly infestation was observed throughout dumpster area. On 7/17/23 at 10:30AM V30 (Dietary Aid) stated the dumpster area is supposed to be maintained in clean condition. This area is not supposed to be in this condition. On 7/19/23 at 3:30PM V1 (Administrator) was asked to provide policy on maintaining dumpster area. On 7/19/23 at 3:30PM V1 stated we do not have a policy for that.