Alta Skilled Nursing and Rehabilitation Center

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a consent was obtained for an opioid pain medication for 1 of 31 sampled residents (Resident #137). This deficient practice had the potential to result in the resident receiving an opioid medication without having been informed of the risks, benefits, and alternatives, and an opportunity to make an informed decision.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to accommodate the needs and preferences for 1 of 31 sampled residents (Resident #26) when the resident requested to get out of bed. This deficient practice had the potential to result in a decline in functional mobility, feelings of isolation and harm to the resident.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was afforded the choice of wearing an identification wrist band for 1 of 31 sampled residents (Resident #23). This deficient practice had the potential to impede a resident's self-determination and right to make choices about aspects of the resident's daily life.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was not punched on the side of the face by another resident in the activity room for 1 of 31 sampled residents (Resident #49). This deficient practice had the potential to result in a resident suffering physical injury and emotional distress causing the resident to avoid socializing in the activity room.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a history of physical and verbal aggression towards other residents had a care plan addressing the aggression implemented for a resident involved in 1 of 5 Facility Reported Incidents (FRI) investigated (Resident #43) and a resident's wound care plan was implemented for 1 of 31 sampled residents (Resident #56). These deficient practices had the potential to result in the resident continuing aggressive behaviors and causing the resident to suffer psychosocial harm from unaddressed behaviors and to negatively impact the physical and psychosocial well-being of other residents in the facility and a resident's wound worsening or becoming infected due to staff not implementing the care plan to complete wound care as ordered.

Inspectors wroteBased on observation, clinical record review, interviews, and document review, the facility failed to ensure professional standards of quality were maintained when medications were left at residents' bedsides and when pain management practices did not adhere to professional standards for 3 of 31 sampled residents (Residents #137, #133, and #6). This deficient practice had the potential to result in unverified and unsupervised medication administration, medication misuse or diversion, adverse medication outcomes, and inadequate pain management.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to 1) ensure a resident's wound care was completed as ordered for 1 of 31 sampled residents (Resident #56). This deficient practice had the potential to result in a resident's wound worsening, a resident developing an infection in the wound, or causing unnecessary pain for a resident.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure medications were not left unsecured at residents' bedside for 1 of 31 sampled residents (Resident #6). This deficient practice had the potential to have medications diverted, medications left unsecured, used or ingested by other residents, and lacked verification of unsupervised medication administration resulting in adverse medication outcomes.

Inspectors wroteBased on interview, observation, clinical record review and document review, the facility failed to ensure a resident's pain was managed with care planned interventions, pain was evaluated per physician orders, and appropriate administration of pain medication for 2 of 31 sampled residents (Resident #71 and #6). This deficient practice had the potential for unrelieved pain, discomfort, and inadequate pain management.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure medications were not left at a resident's bedside unattended for 1 of 31 sampled residents (Resident #133). This deficient practice had the potential to result in facility residents accessing and ingesting medications with the potential for severe or lethal consequences and unauthorized individuals having access to resident medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure 500 and 600 hall satellite resident pantry and refrigerator food and drink items were protected from cross contamination. This deficient practice had the potential to affect residents in 500 and 600 hall by increasing the risk of cross contamination and causing infection and foodborne illnesses.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's record contained accurate documentation of a resident's wound care for 1 of 31 sampled residents (Resident #56). This deficient practice had the potential to cause a resident's wound to worsen without staff's knowledge and cause a delay in necessary treatment to prevent infection or promote healing.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure staff performed hand hygiene in between glove changes when providing wound care to 1 of 31 sampled residents (Resident #9). This deficient practice had the potential to contaminate a wound and spread infection causing a resident to experience delayed healing or prolonged illness.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's Care Plan was integrated with the hospice plan of care and included a care plan addressing the resident's wound care for 1 of 32 sampled residents (Resident #19). This deficient practice had the potential to result in staff caring for the resident not being aware of the care to be provided to the resident by hospice staff versus care to be provided by facility staff leading to a potential decline in the quality of care the resident received in the facility and the resident not receiving wound care as ordered.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure resident's care plans were updated to include a resident's need for an appointment with a neurologist due to an increase in the resident's tremors from Parkinson's disease and a resident's continued habit of smoking and storing smoking paraphernalia in the resident's room for 2 of 32 residents (Resident #25 and #13). This deficient practice had the potential to result in staff not being aware of a resident's need for an appointment with a specialist physician to address a resident's medical needs and staff not being aware of the need to continue to assess a resident for safety concerns related to the resident smoking independently and keeping smoking paraphernalia in the resident's room.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's physician order for a neurologist referral due to an increase in the resident's tremors from Parkinson's disease was acted on in a timely manner and monitored for completeness by clinical leadership for 1 of 32 sampled residents (Resident #25). This deficient practice had the potential to result in a resident's symptoms not being managed timely and causing a resident unnecessary discomfort and decreased quality of life from a delay in care.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a resident determined to be at risk for pressure injury did not develop a pressure injury, and 2) a resident received wound care per physician orders and the facility policy for 1 of 32 sampled residents (Resident #3). The deficient practices had the potential to place the resident at risk for delayed wound healing and infection.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure a resident's gastric residual volume (the amount of fluid remaining in the stomach) was checked prior to administration of a medication via the resident's gastrostomy tube (a feeding tube providing a direct path to the stomach for delivering nutrition, fluids, and medications) (G-tube) for 1 of 32 sampled residents (Resident #84). This deficient practice had the potential for delayed gastric emptying to not be recognized in a resident with the potential to result in aspiration pneumonia (a type of lung infection due to inhaling substances into the lungs).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure there were no discrepancies between a resident's available medications and the resident's medication orders and medication administration record (MAR) for 1 of 32 sampled residents (Resident #19). This deficient practice had the potential to result in a resident not receiving medications the resident could have potentially needed to alleviate symptoms of anxiety, agitation, restlessness, nausea, and vomiting.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an unattended medication cart was not left unlocked with the keys to the medication cart on top of the cart for 1 of 1 medication carts in use on the 300 hall. This deficient practice had the potential to result in facility residents accessing and ingesting medications with the potential for severe or lethal consequences and unauthorized individuals having access to resident's medications.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the facility coordinated care and services with a hospice agency providing care and medications to a resident residing in the facility for 1 of 32 sampled residents (Resident #19). This deficient practice had the potential to result in a resident not receiving care or medications as ordered due to a lack of coordination and communication between the facility and hospice agency with the potential for the resident to suffer neglect or end-of-life symptoms not managed by facility staff.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a staff member conducted hand hygiene prior to entering a room on enhanced barrier precautions (EBP) for 1 of 44 rooms on EBP and for 1 of 32 sampled residents (Resident #73). This deficient practice had the potential to affect the resident population.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a wound cart and medication cart containing resident medications was secure. The deficient practice could have facilitated unauthorized access to medications in the carts.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure residents were screened for eligibility to receive a pneumococcal vaccination, education regarding the vaccine was provided to the resident and/or the Resident Representative, and the vaccine was offered and either administered or declined for 28 of 163 residents in the facility (Resident #410, #158, #255, #163, #106, #112, #85, #17, #27, #124, #9, #83, #50, #156, #47, #155, #61, #8, #117, #81, #161, #310, #115, #55, #18, #122, #46 and #104).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident's representative and the resident's physician was notified of a change in the resident's condition for 1 of 3 sampled residents reviewed for closed records (Resident #305). This deficient practice had the potential to result in a resident's representative and physician being unaware of significant decline in a resident's physical well-being and the resident suffering physical harm without family support or medical intervention.

Inspectors wroteBased on observation, interview, clinical record, and document review, the facility failed to provide a comfortable, homelike environment when the facility was made aware of a broken air conditioning (AC) unit in a resident room and did not act to fix the unit or offer an accommodation to the resident for 1 of 33 sampled residents (Resident #257).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident was not physically abused by another resident for 2 of 2 residents investigated for resident to resident abuse (Resident #83 and #122).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a resident's report of missing money was investigated per facility policy for 1 of 33 sampled residents (Resident #149). The deficient practice had the potential to result in missing resident belongings not being recovered or misappropriation of resident property not being investigated by the facility.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a urinary catheter and the behavior of pulling out the urinary catheter had the resident's urinary catheter care plan revised to include interventions to prevent the resident from continuing to pull out the catheter for 1 of 33 sampled residents (Resident #98). This deficient practice had the potential to result in the resident sustaining further injury from the behavior.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's medical record was complete for 3 of 33 sampled residents (Resident #143, #455 and #205). This deficient practice had the potential to result in the resident sustaining significant weight loss and unrecognized complications from a improperly cared for G-tube.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to provide protective supervision when a resident wearing a wander device followed an employee out of an alarmed exit door, the alarm system failed to work, and the resident was found wandering around in the parking lot for 1 of 1 residents investigated for elopement (Resident #411).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure 2 of 33 sampled residents (Resident #37 and #143) were weighed per facility policy.

Inspectors wroteBased on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 1 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #8).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure ordered medications were available and administered for 1 of 33 sampled residents (Resident #18).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1)a resident with a urinary catheter and the behavior of pulling out the urinary catheter had interventions in place to reduce the risk of the resident continuing the behavior and prevent further physical trauma related to the behavior for 1 of 33 sampled residents (Resident #98), 2) the facility provided care according to the facilities standard of practice to a resident with a deep vein thrombosis (DVT) (a blood clot in one or more of the deep veins in the body) for 1 of 3 residents reviewed for closed records (Resident #305) and 3) a physician's order from hospice was communicated to the facility's physician and the resident received an ordered medication for 1 of 33 sampled residents (Resident #455). [...]

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented when providing care to a resident's jejunostomy tube (J-tube) for 1 of 33 sampled residents (Resident #109).

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure a resident's dignity was maintained for 1 of 18 sampled residents (Resident #9). Resident #9 Resident #9 was admitted to the facility on [DATE] with a diagnosis including hydrocephalus and difficulty walking. A Facility Reported Incident (FRI) documented on 02/23/2024, the allegation a Physical Therapist (PT) was witnessed verbally berating a resident at the nurse's station. A Communication Note dated 02/23/2024, documented the writer spoke with Resident #9 regarding the interaction with the PT. Resident #9 expressed the resident was okay and the interaction was just a misunderstanding. The writer expressed to the resident the PT was just trying to make sure the resident was safe since the resident was not cleared to ambulate on their own. [...]

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure 1) a resident was kept safe from verbal abuse by a staff member for 1 of 18 sampled residents (Resident #7).

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure the policy pertaining to abuse investigations and reporting was implemented. An allegation of abuse was not investigated or reported to law enforcement or the State agency for 1 of 18 sampled residents (Resident #2) placing the resident at continued risk of physical abuse by a staff member.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure an allegation of physical abuse against a resident by a staff member was reported within the two-hour time frame for 1 of 18 sampled residents (Resident #2). This deficient practice could allow allegations of abuse to occur and not be reported for investigation.

Inspectors wroteBased on interview, record review, and document review, the facility failed to investigate a resident's allegation of abuse for 1 of 18 sampled residents (Resident #2). Resident #2 alleged a Certified Nursing Assistant (CNA) slapped the resident and handled the resident roughly when providing care. The CNA named in the abuse allegation was scheduled to work with the resident of concern and throughout the facility from the time the facility was made aware of the allegation on [DATE], until [DATE]. The facility did not report the incident to the State Survey Agency or law enforcement. The lack of investigation and measures to prevent further potential abuse allowed the alleged perpetrator continued access, with the potential for further physical abuse and harm, to the alleged victim and all residents within the CNA's assignment. [...]

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) had the competencies necessary to safely perform medication administration for 1 of 2 nurses observed for medication administration observations.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a resident's medications were administered as ordered and not left at the bedside for 1 of 18 sampled residents (Resident #1). Bedtime medications from 04/02/2024 and morning medications from 04/03/2024 were left at the bedside of the resident for the resident to take without staff supervision for a total of 10 out of 10 medications not administered as ordered, creating the potential for oversedation and a higher risk of drug-to-drug interactions. The medication error rate was 100 percent (%).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure cups containing a laxative powder dissolved in cups of water, were not stored on the top of the medication cart when not in sight of a staff member with the potential for the medication to be ingested by other residents or visitors for 3 of 3 premixed cups of the medication and unlocked medication carts were not left unattended. The laxative powder had potential common side effects including bloating, gas, upset stomach, and dizziness.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to protect the residents' right to be free from physical abuse by a resident for 2 of 13 Facility Reported Incidents (FRI) (Resident #8, #9, #7 and #5).

Inspectors wroteBased on clinical record review, interview, and document review the facility failed to ensure Facility Reported Incidents (FRI) were completed and submitted to the State Survey Agency within the required time for an allegation of resident to resident physical abuse for 1 out of 18 sampled residents (Resident #5 and #7)

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications were not left unsecured in a medication cart on the 300 hallway.