Las Alturas De Penitas

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #5) of 3 residents reviewed for Advance Directives. The facility failed to ensure Resident #5's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature dated, printed name or License number. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to ensure all pre-admission screening and resident review (PASRR) Level 1 residents with mental illness were provided with an accurate PASRR Level 1 for 1 (Resident #93) of 3 residents reviewed for PASRR screening. Resident #93 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #69) residents reviewed for tracheostomy/respiratory care. The facility failed to ensure Resident #69's oxygen tubing was connected properly to the tracheostomy mask (used to deliver humidified air and oxygen) on 05/26/26. The facility failed to ensure Resident #69's oxygen was administered at the correct setting of 5 liters per minute (LPM) on 05/26/26 as ordered by the physician. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 2 (Resident #13 and Resident #43) of 4 resident refrigerators reviewed for refrigerator sanitation. The facility failed to ensure Resident #13 and Resident #43's personal refrigerator did not contain food that was not labeled, dated or expired. Resident #13's personal refrigerator had 3 small individual cups of yogurt that had no expiration date and a plastic ziploc bag with candy pieces that was not labeled or dated. Resident #43's personal refrigerator had 4 small probiotic drink bottles with no expiration date on them and 1 individual cup of yogurt that was expired. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure Resident #1 was administered her order of Sodium Chloride Solution 0.9% as ordered. This failure could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 6 residents (Resident #22) reviewed for respiratory care. The facility failed to ensure Resident #22's oxygen was administered at 2 lmp instead of 2.5 lpm via nasal cannula as ordered by physician. This failure could place resident(s) at risk of developing respiratory complications and having a decreased quality of care.

Inspectors wroteBased on observation, record review, and interview, 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 2 (Resident #36 and Resident # 78) out of 4. 1. LVN A did not perform hand hygiene for 20 seconds or longer after medication administration to Resident #36. 2. The facility failed to prevent Resident#78's urinary catheter bag/tubing from touching the floor. These failures could place residents at risk for infection through cross contamination of pathogens.

Inspectors wroteBased on interview and record reviews the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 3 residents (Resident #24, Resident #25 and Resident #26) reviewed for abuse. 1. The facility failed to ensure Resident #26 did not inappropriately touch Resident #25 in the groin area, over his clothing, on 02/10/24 . 2. The facility failed to ensure Resident #26 did not inappropriately touch Resident #24 in the breast area on 04/16/24. An Immediate Jeopardy (IJ) situation was identified on 01/30/25. While the IJ was removed on 01/31/25 at 2:09 p.m., the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for three of three residents (Resident#24, Resident#25, and Resident#26) reviewed for reporting abuse. The facility failed to report two separate incidents of resident-to-resident abuse to the state agency within the given time frame. This failure could place residents at increased risk for potential abuse.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of three residents (Resident#26) reviewed for comprehensive person centered care plan . The facility failed to ensure Resident #26's care plan reflected the need for interventions for monitoring inappropriate behaviors with residents after 2 separate incidents of inappropriate behavior with 2 Residents (Resident #24 and Resident #25) had occurred . [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1 of residents (Resident #1) reviewed for accidents and hazards, CNA A failed to transfer Resident #1 using two employees as required by his care plan. This deficient practice has the potential to affect all residents in the building who require assistance with transfers by 2 staff members by causing resident injuries, such as falls, fractures, and even death.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 residents (Resident #1) reviewed for quality of care. The facility failed to identify a chnge in condtion for 9 hour for Resident #1, across 2 shifts on 01/14.24. An Immediate Jeopardy (IJ) situation was identified on 01/23/24. While the Immediate Jeopardy was removed on 01/26/24 at 10:36 am, the facility remained out of compliance at a scope of pattern with no actual harm that is immediate, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at increased risk of decline in physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance,unless the resident's clinical condition demonstrated that this was not possible, or resident preferences indicate otherwise for one of nine residents reviewed for nutrition. The facility failed to ensure Resident #1 did not sustain a significant weight loss of 18.18% in a 30-day period. An Immediate Jeopardy (IJ) situation was identified on 01/23/24. While the Immediate Jeopardy was removed on 01/26/24 at 10:36 am, the facility remained out of compliance at a scope of pattern with no actual harm that is immediate, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at increased risk of decline in physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision / interventions for 2 residents (Resident #1 and Resident #99) of 5 residents reviewed for supervision / interventions, in that The facility failed to ensure Resident #1, and Resident #99 received supervision and interventions to prevent Resident #1 and Resident #99 from repeated falls with injuries. An Immediate Jeopardy was identified on 12/15/23. The Immediate Jeopardy template was provided to the facility Administrator on 12/15/23 at 04:35 p.m. While the Immediate Jeopardy was removed on 12/18/23 at 04:45 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported immediately to the State Survey Agency, within two hours, if the events that cause the allegation involve abuse or result in serious injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious injury for 1 resident (Resident #1) of 3 residents reviewed for abuse/neglect, The facility did not report the allegation of resident abuse to the State Survey Agency within the allotted time frame for Resident #1 who had unwitnessed falls and/or falls withinjury on 12/03/22 (left hip fracture) and 08/26/23 (right hip fracture). [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #45) of 5 residents reviewed for medication administration. Resident #45 had Metoprolol (a medication for high blood pressure) administered outside the parameters as ordered by the physician. This deficient practice could place residents who receive blood pressure medications at an increased risk for complications such as decreased blood pressure, decrease pulse, an exacerbation of symptoms and disease process, and potential hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to ensure services were provided with adequate use of assistive devices to prevent accidents for 1 of 5 residents, Resident #5 (R #5) reviewed for accidents. The facility failed to ensure staff were adequately trained in the use of mechanical lifts needed for resident transfers. CNA C and NAIT D did not ensure mechanical lift sling was properly attached to the lift's hooking mechanism when transferring R #5, resulting in sling releasing from hook and R #5 landing face first on the floor, which caused R #5 to sustain a mild right temporal subdural acute hematoma, interhemispheric subdural hematoma, bilateral nasal bone fractures, left medial orbital fracture, forehead/nasal bridge lacerations, and 9 stitches (8 on top of his left eye and 1 on his nose bridge). [...]