Las Alturas Nursing & Transitional Care Brownsvill

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident#1) of 4 residents, reviewed for pharmaceutical services, in that:The facility failed to ensure Resident #1's physician ordered Midodrine (medication used to raise blood pressure) was held when her blood pressure was found to be out of parameters for administration. This failure could place residents at risk of not receiving the therapeutic effect of their medication as ordered by the physician.

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 (200 hallway) of 4 medication carts. The facility failed to ensure the nurses medication cart for 200 hall was secured by a lock when it was left unattended by LVN A. This failure could place residents at risk of injury to other residents if medication left unsecured were consumed.

Inspectors wroteBased on interview and record review, the facility failed 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 1 (Resident # 1) of 2 residents reviewed for parenteral fluids. The facility failed to ensure on 8/15/2025 that Resident # 1's intravenous medication bag was correctly labeled with the resident's name. This failure could place residents at risk for medication error and delay in medication administration.

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 2 (Resident #34 and Resident #60) of 25 residents reviewed for call lights. The facility failed to ensure Resident #34 and Resident #60 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 interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #173) of 8 residents reviewed for Advance Directives. The facility failed to ensure Resident #173's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. 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 wroteBased on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 2 of 3 (Resident #1, Resident #41) reviewed for notifying the LTC Ombudsman of the residents' discharge. 1. Resident #1 was discharged to the hospital on [DATE] without a notice to the LTC state ombudsman. 2. Resident #41 was discharged home on [DATE] without a notice to the LTC state ombudsman. These failures could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 2 of 8 residents reviewed for PASRR. (Resident #20, Resident #22)1. The facility failed to refer Resident #20 for PASRR Level II assessment when the facility incorrectly coded her PASRR Level I assessment.2. The facility failed to refer Resident #22 for PASRR review following new mental illness diagnosis of Major Depressive Disorder, added on 04/30/2025. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interview, and record review, the facility failed to implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 22 residents (Resident #20) reviewed for care plans. The facility did not develop Resident #20's care plan related to diagnosis Post-Traumatic Stress Disorder. These failures could place residents at risk for unmet care needs and decreased quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 5 residents (Resident #29) reviewed for tube feeding management. The facility failed to ensure there were labels or instructions on Resident #29' s enteral nutrition supplemental feeding bottle on 06/29/25. These failures could place residents at risk for non-therapeutic responses to enteral feeding, as well as receiving the wrong feeding or receiving a feeding at the wrong rate.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #61) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #61's oxygen was administered at the correct setting of 2 liters per minute on 06/29/2025 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation, interviews, 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 1 of 4 Residents (Resident #39) that were observed for infection control in that: The facility failed to ensure CNA E performed proper hand hygiene during pericare (incontinent care) for Resident #39. The facility failed to ensure CNA F performed proper Foley catheter care for Resident #39. These deficient practices could place residents at risk for infections, healthcare associated cross contamination, and the spread of infection.

Inspectors wroteBased on interviews and record review, the facility failed to ensure adequate supervision was provided for 1 of 3 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on 02/12/2025 and was found by the police department approximately 2700 feet (0.5 mile) away from the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 02/12/2025 and ended on 02/13/2025. The facility had corrected the noncompliance before the survey began. This failure could prevent residents from receiving appropriate supervision which could lead to residents sustaining serious injury, harm, or death.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement baseline care plans that included the instructions needed to provide effective and person-centered care within 48 hours of admission for 2 of 4 residents (Resident #3 and Resident #2) reviewed for baseline care plans: 1. The facility failed to complete Resident #3's baseline care plan within 48 hours. 2. The facility failed to include in her baseline care plan that Resident #2's was admitted with a PICC line to upper right arm. These deficient practices could affect residents who receive care at the facility and could result in missed or inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that ensure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 3 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure that on 11/01/2024, LVN A signed off the administration of PRN acetaminophen to Resident #1 that was administered for a skin tear sustained after a transfer. These failure could place residents at risk for not receiving the therapeutic benefits of the prescribed medications and side effects from missed doses.