Alta Vista Rehabilitation and Healthcare

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #1) reviewed for administration. The facility failed to ensure LVN A documented accurate nursing progress notes for Resident # 1 after the TPN was discontinued. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be informed in advance, by the physician or other practitioner or professional of the risks and benefits of proposed care, treatment and treatment alternatives for one (Resident #1) of three residents reviewed for consent of psychoactive medications. The facility failed to obtain consent from the resident or responsible party for Trazodone (antidepressant) for Resident #1. This failure could affect residents receiving antidepressants medications, by contributing to residents/responsible parties not being fully informed of the benefits and/or side effects and risks associated with these medications, placing residents at risk for receiving psychoactive medications without consent.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for one (Resident #1) of three sampled residents reviewed for unnecessary drugs. Resident #1 received an anti-depressant medication, Trazodone, without a consent form signed. These failures could cause residents to have side effects, adverse medication reactions, or allergic reactions to medications that were unnecessary.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (wound care cart) of 5 medication carts. The facility failed to ensure the wound care medication cart was secured and lock when it was left unattended by RN A. This failure could place residents at risk of injury to other residents if medication left unsecured were consumed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety requirements in 1 of 1 kitchen reviewed for kitchen sanitation.1. The facility failed to not store personal beverages in the food preparation area.2. The facility failed to ensure dented can were placed in a separate storage area.3. The facility failed to properly thaw raw meat that was observed in the sink designated for produce only. The raw meat was not under running water and had red liquid draining into the sinks drain.4. The facility failed to ensure clean cups were free of debris. These failures could place residents at risk for food contamination and food borne illnesses.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #12) reviewed for resident rights. The facility failed to notify Resident #12's RP she had a Wanderguard place on 08/27/25. This failure could place residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 (Resident #12) residents reviewed for accuracy of assessments. The facility failed to ensure Resident #12 was coded as having wandering behavior and a wander alarm on her MDS assessment dated [DATE]. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and a comprehensive care plan for each resident, with the resident's rights, that includes measurable short-term and long-term objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident # 4) reviewed for care plans that: The facility failed to ensure Resident # 4's care plan included her triggers for a diagnosis of Post Traumatic Stress Disorder (PTSD). This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for 1 (Resident #79) of 25 residents reviewed for call lights. The facility failed to ensure Resident #79 had the call light within reach while in bed in their room. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 residents (Resident #35) reviewed forThe facility failed to ensure Resident #35's order for a nutritional supplement included the route of administration and prescribed dose. The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for 1 of 25 residents (Resident #71) observed for infection control. 1. The facility failed to ensure LVN A used the required Personal Protective Equipment (gown) for Resident #71, who was on enhanced barrier precautions due to her sacral wound during wound care on 9/22/25. 2. The facility failed to ensure LVN A performed hand hygiene while providing wound care to Resident #71 on 09/22/25 and failed to ensure LVN A lather her hands for at least 20 seconds. These failures could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and Resident #2) of 11 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1's fall on [DATE] was accurately coded in the MDS assessment. The facility failed to ensure Resident #2's fall on [DATE] was accurately coded in the MDS assessment. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care received such care consistent with professional standards of practice for 3 of 4 residents (Resident #225, Resident #18, and Resident 48) reviewed for respiratory care. The facility failed to ensure: 1. Resident #225 received oxygen at the prescribed rate. Resident #225 received oxygen at a rate less than prescribed. 2. Resident #18's oxygen was administered at 3 Lpm instead of 2 Lpm via nasal cannula as ordered by physician. 3. Resident #48 's oxygen was administered at 3.5 Liters Per Minute instead of 4 Liters Per Minute via nasal cannula as ordered by the physician. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care.

Inspectors wroteBased on observation, interview, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that includes measurable objectives and time frames to meet residents' physical needs for 2 (Resident #48 and #225) of 24 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure: 1. Resident #225's care plan developed on 8/2/2024 reflected oxygen use. 2. to develop a comprehensive person-centered care plan for Resident #48 addressing the oxygen therapy. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments, person-centered care plan to reflect the current condition for 1 of 4 residents (Resident #18) reviewed for care plan revisions. The facility failed to ensure Resident #18's care plan was updated to reflect the Oxygen order effective 07/30/2024. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that nurses were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 2 residents (Resident #48) by 1 of 2 nurses (LVN A) reviewed for competent staff, in that: LVN A failed to check G-tube residual prior to administering medication for Resident #48. This failure could place residents at risk for not receiving nursing services by adequately trained and licensed nurses and could result in a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety for 1 of 3 mini refrigerators reviewed for sanitation in that: The facility failed to ensure the food items in Resident # 39's mini refrigerator were labeled and dated. This failure could place residents at risk of foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 4 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report allegations made by one CNA about another CNA of verbal and physical resident abuse. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately inform the resident, consult with the resident physician, and notify the resident's representative when there was a significant change in the resident's physical mental or psychological status for 1 of 5 residents (Resident #1) reviewed for notification of change of condition. The facility failed to notify the resident's physician when R#1's abnormal skin condition was identified on 09/09/23. R#1 was transferred to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. This failure could affect residents with acute ischemia by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 09/19/23 at 6:10 pm. [...]

Inspectors wroteBased on interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 (Resident #1) reviewed for quality of care. The facility failed to document, monitor, and assess Resident #1's abnormal skin discoloration for approximately 39 hours. Resident #1 was transferred to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. This failure could affect residents with acute ischemia by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. This failure resulted in an identification of Immediate Jeopardy (IJ) on 09/19/23 at 6:10 pm. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessments for one resident (Resident #1) of 5 residents reviewed for care. RN A's failure to document, monitor, and assess R#1's abnormal skin discoloration for approximately 39 hours resulted in R#1's transfer to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #1) reviewed for medical records . The facility failed to ensure RN A documented in the clinical records that Resident #1 had a change in condition of discoloration to the resident's inner thigh. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the resident's care and place residents at risk for harm due to inaccurate records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for 1 (Resident #70) out of 7 residents reviewed for significant medication errors in that: 1. LVN H administered Potassium Chloride liquid 20 meq (milliequivalents)/15 mL (milliliters) via g-tube (gastric tube) without diluting with 4-6 ounces of water prior to administration 26 times from 03/01/23-04/25/23 2. LVN H failed to administer 5mL (milliliters) of Chlorhexidine Gluconate 0.12% solution via g-tube as ordered by physician for Resident #70 and without confirming the order with the physician prior to administering the medication 55 times from 03/03/23-04/25/23. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #81, Resident #23, Resident #11) reviewed for care plans in that: 1. Resident #81 did not have a care plan in place for wound vac use. 2. Resident #23 did not have a care plan in place for wound vac use. 3. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #11 to address skin scratches to bilateral lower extremities. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of medication error rates of five percent. There were 2 errors in 25 opportunities which resulted in an 8% error rate involving 1 of 4 residents (Resident #70) observed. 1. LVN H administered Potassium Chloride liquid 20 meq (milliequivalents)/15 mL (milliliters) via g-tube (gastric tube) without diluting with 4-6 ounces of water prior to administration. 2. LVN H failed to administer 5mL (milliliters) of Chlorhexidine Gluconate 0.12% solution via g-tube as ordered by physician for Resident #70 and without confirming the order with the physician prior to administering the medication. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to 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, for one resident (Resident #191) observed for incontinent care, in that: CNA B did not perform handwashing for 20 seconds or more after before and after providing incontinent care for Resident #191. CNA A did not perform handwashing for 20 seconds or more after providing incontinent care for Resident #191. This failure could place residents at risk for infections and cross contamination.