Alta Vista Healthcare & Wellness Centre

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation and monitoring parameters for the antipsychotic medication Quetiapine (an antipsychotic medication used to treat psychiatric conditions) for one of three residents reviewed (Resident 1). This failure had the potential to delay identification of adverse side effects associated with antipsychotic medication use, including changes in condition, excessive sedation, abnormal movements, and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was revised to reflect new physician recommendations and resident's worsening skin condition for one of one resident reviewed for skin condition (Resident 4). This failure had the potential to result in Resident 4's skin rash worsening and not being appropriately addressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided meet professional standards of practice for one of five residents reviewed (Resident 4) when the facility did not clarify the physician's order for behavior monitoring during the use of an antipsychotic medication (drugs that affect brain chemicals to stabilize mood and thoughts), Vraylar (an antipsychotic medication used to treat bipolar disorder and schizophrenia). These failures had the potential for Resident 4 to receive Vraylar without adequate target behavior monitoring to assess the effectiveness of the medication. A review of Resident 4's admission Record, dated August 7, 2025, indicated Resident 4 was admitted on [DATE], with diagnosis of bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to maintain intravenous (the administration of fluids, medications directly into a vein) access for two of eight residents (Resident 6 and 68) when: 1. Resident 6's PICC line (peripherally inserted central catheter) dressing was changed in a timely manner.2. Resident 68's peripheral dressing (a transparent covering placed over a peripheral intravenous insertion site) was labeled with the date, time and nurse's initials. These failures had the potential to delay the identification of intravenous catheter-related complications and result in infection, placing the residents at risk for worsened health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of one sampled resident reviewed for respiratory care (Resident 9) the licensed staff document before and after nebulizer assessments as ordered by the physician and evaluate the effectiveness of treatment. This failure had the potential to cause Resident 9 not to receive effective treatment and relief during episodes of respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain assessment and management were performed, for two of four residents reviewed (Resident's 12 and 7). This failure had the potential for Resident's 12 and 7 to experience pain and discomfort which could negatively impact mental and physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate intervention was provided after a dialysis (the process of removing excess water and cleaning the blood in people whose kidneys no longer work) treatment for one of three residents reviewed for dialysis (Resident 42) when a post dialysis evaluation was not completed on August 7, 2025. This failure to assess and document Resident 42's health status after dialysis had the potential to result in unrecognized complications and delayed interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1a. Medication Room in Nursing Station 1 contained one (1) refrigerated medication vial opened without an open date label; and 1b. Medication Cart in Nursing Station 3 contained three (3) medications opened without an open date label. The deficient practices had a potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock.1a. During a concurrent observation and interview on [DATE] at 12:09 p.m. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow the physician's order to hold the medication Furosemide (water pill) for blood pressure less than 110, for one out of three sampled residents reviewed (Resident 1). This failure had the potential to result in hypotension, placing Resident 1 at risk for medical emergency. Findings. A review of Resident 1's admission recorded indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses which included localized edema (swelling) and pulmonary hypertension (high blood pressure in the arteries of the lungs). A review of Resident 1's physician order dated January 26, 2025, indicated .Furosemide Oral Tablet 40 MG .Give 1 tablet by mouth one time a day for edema hold if SBP (systolic blood pressure - measures the pressure in the arteries when the heart beats and pumps blood) is < (less than) 110. [...]

Inspectors wroteBased on record review, interviews, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) user's manual, the facility failed to accurately code the Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) to reflect a Preadmission Screening and Resident Review (PASRR) Level II for 4 (Residents #14, #55, #62, and #80) of 6 sampled residents reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure care of a peripheral intravenous (IV) access site was provided and documented in accordance with accepted standards of nursing practice and facility policy for 1 (Resident #55) of 1 sampled resident reviewed for IV site care. Specifically, the facility failed to obtain physician's orders for IV flushes and dressing changes, failed to conduct and document assessments of the IV site, and failed to ensure the IV site was discontinued promptly when not needed for IV therapy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure splints were applied as ordered for 2 (Resident #18 and Resident #46) of 3 sampled residents reviewed for positioning and mobility.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure an as-needed (PRN) psychotropic medication order was limited to 14 days unless there was documented rationale for the extended use and a specific duration of the order. This affected 1 (Resident #27) of 5 residents reviewed for unnecessary medications. Resident #27 had a PRN order for Ativan (a benzodiazepine) with no stop date or documented rationale for the continued use.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a glucometer (device used to check blood glucose levels) was cleaned and disinfected between use to prevent the potential spread of infection for 2 (Resident #7 and Resident #26) of 4 residents observed receiving blood glucose checks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 3), was assisted with his meal in a dignified manner when the Certified Nursing Assistant (CNA 2), stood over the resident. This failure caused Resident 3 to feel rushed and had the potential for compromised dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure basic accommodations of needs were met when one of three residents, (Resident 1) ' s call light was not within reach. This failure had the potential for Resident 1 to have unmet needs and unable to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to assess the need for duplicated medication (Depakote-medication for seizure and mood stabilizer for behavior management) to manage behavior for one of five sampled residents (Resident 1). This failure had resulted for Resident 1 to receive two different forms of Depakote for 11 days which could potentially cause drug adverse reaction, complication, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to prevent administration of unnecessary medication to one of five sampled residents (Resident 1), when Resident 1 was administered with Depakote (medication used to treat seizures and bipolar disorder)DR (delayed released -delayed release of drugs in the body) and Depakote ER (extended released-drug is released slowly to provide a prolonged therapeutic effect), at bedtime without adequate indication for duplicated use. The facility failure had resulted in Resident 1 receiving unnecessary medication for 11 days which could potentially cause drug adverse reaction, complications, and unnecessary hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for three of five residents reviewed for PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care): a. The evaluation for PASRR level II (identifies the specialized services required by the resident) was cooordinated with State-Designated Authority (SDA), for Resident 75. This failure may result to the facility's inability to incorporate PASRR Level II evaluation in the resident's care plan. In addition, Resident 75 specialized services were not met, and b. PASRR level I assessment was coded accurately for Residents 51 and 67. This failure had the potential to result in admitting residents that were not appropriate in the facility and for Residents 51 and 67 not to receive the appropriate services.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with the professional standards of practice for two of 18 residents reviewed (Residents 67 and 88) when: 1a. The licensed nurse did not clarify the dose of the medication Roxanol (Morphine: opioid medicine used to treat moderate to severe pain) with the physician for Resident 88. This failure had the potential for Resident 88 to receive the wrong dose of Roxanol; 1b. The intake and output was not monitored as ordered by the physician for Resident 88. This failure had the potential to result in fluid overload. 2. Turning and repositioning was not implemented in accordance to the schedule for Resident 67. This failure had the potential to result in skin breakdown for Resident 67.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative nursing services (nursing interventions that promote quality of life by increasing the resident level of strength and mobility and maintain his or her maximum functional capacity) as ordered by the physician for three of five residents reviewed for limited range of motion (ROM-the full movement potential of joint) (Residents 19, 52, and 67). This failure had the potential to result in the resident's decline in ROM and deterioration in their ability to perform activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe food handling practices when: 1. The food products located in the resident's refrigerator were not labeled. 2a. The interior of the microwave oven was observed with dark yellowish substance; and 2b. The convection oven was observed with dust particles and dark brownish material. These failures had the potential to result in foodborne illnesses in the highly susceptible resident population. Findings. 1. On July 23, 2021 at 11:12 a.m., during the inspection of the resident's refrigerator in the Yellow zone with the Infection Preventionist (IP), the following were observed: a. One bag filled with multiple sandwiches was found not labeled with names and date; b. One white plastic bag containing food was not labeled with name and date; c. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure for two of eight residents reviewed: 1. An Advance Directive (written instruction, such as a living will or durable power of attorney for healthcare, recognized under State Law, relating to the provision of healthcare when the individual is incapacitated) was discussed with their responsible party, for Resident 43; and This failure had the potential for the residents to not receive their preplanned treatment and services in the event they were incapacitated and/or unable to speak for themselves. 2. The Advance Directive was in the medical chart and easily accessible to the staff for Resident 51. This failure had the potential for Resident 51's Advance Directive to not be readily retrievable by the staff, by the physician, not knowing the wishes of the resident regarding medical treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurse notified the physician of the resident's change of condition for one of 18 residents reviewed (Resident 88). This failure had the potential for Resident 88 not to receive the appropriate treatment to address his medical needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address a concern on room temperature during mealtime, for one of sixteen residents observed (Resident 25). This failure had the potential to result in resident not having the quality of life she deserved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan to address impairment in communication was implemented, when the language communication board was not accessible for the staff to use when providing care for one of five residents reviewed (Resident 62). This failure has the potential for the resident not to be able to effectively communicate his needs to the staff which could result in unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were followed in accordance with the professional standards of practice, for one of five residents (Resident 2), when Zinc (supplement) was not transcribed correctly and was not administered according to the physicians order for Resident 2. These failures had the potential for residents to experience unmet healthcare needs .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment free of accident hazard, when a floor mat on the right side of the bed was not provided in accordance to the plan of care for one of four residents reviewed (Resident 19). This failure had the potential for Resident 19 to sustain injuries from a fall.

Inspectors wroteBased on interview and record review, the facility failed address the pharmacy recommendation on Ativan (lorazepam- used to treat anxiety) use, for one of five residents reviewed for unnecessary medications (Resident 4). This failure had the potential for Resident 4 to receive Ativan unnecessarily. In addition, Resident 4 was not reevaluated by the physician prior to continuing the use of Ativan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired and outdated medications were not stored and readily available for use. This failure could expose residents to expired medications with questionable potency and efficacy. Findings. On July 21, 2021, at 11:15 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 2, during a medication storage inspection in the designated yellow zone. One unopened box labeled; Geri-care Ear drops (carbamide peroxide 6.5% Ear wax removal solution) with expiration date of June 21, 2021, was observed stored in the top shelf of the medication storage cabinet. On July 21, 2021, at 11:20 a.m., LVN 2 stated the Geri-care Ear drops for ear wax removal should not have been in the cabinet past the expiration date. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, for two of 18 residents reviewed (Residents 49 and 79), the following: a. The routine A1C (blood test that measures blood sugar level over the past three months), CMP (comprehensive metabolic panel blood test often used to evaluate liver function, kidney function, and nutrient levels) and lipid panel (the amount of specific fat molecules called lipids in the blood) was obtained, as ordered by the physician for Resident 49. This failure resulted for the routine laboratory to not be completed as ordered which could result in the delay in Resident 49's care and treatment; and b. The urine analysis was reported to the physician promptly for Resident 79. This failure had the potential to result in the delay of care and treatment for Resident 79 medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide specialized rehabilitative (rehab) services, as ordered by the physician, for one of two residents reviewed for rehab (Resident 59), when PT and OT did not evaluate and treat Resident 59. This failure had the potential to result in Resident 59's difficulty in attaining and maintaining her highest practicable level of physical, mental, functional, and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of 18 residents reviewed (Resident 79), an adequate indication for the use of Macrobid (antibiotic to treat urinary tract infection ) . This failure had the potential to result in emergence of antibiotic resistant organisms.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for two of five residents reviewed: a. Education was provided to Resident 65 when the resident refused the influenza vaccine. This failure did not honor the resident right to be notified in order to make an informed choice for Resident 65 regarding the vaccine. b. Education was provided to the resident's responsible party about pneumococcal vaccine (prevents infection by Streptococcus [bacterium that causes one of the most common and severe forms of pneumonia] [pneumonia-lung inflammation]), benefits and potential side effects. This failure did not honor the responsible party's right to be notified in order to make an informed choice for Resident 75 regarding the vaccine.

Inspectors wroteBased on interview and record review, the facility failed to accommodate the request for COVID 19 (Corona virus disease 2019- a respiratory disease caused by a virus that can be transmitted from person to person) vaccine for one of five residents reviewed for immunization for COVID 19 (Resident 78). This failure had the potential to result in Resident 78 not getting the protection from the virus.