Alpine Valley Post Acute and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Alpine Valley Post Acute and Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF684Sep 20, 2024

  Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 19 sampled residents. (Resident 60) Findings include: Clinical record review revealed that Resident 60 had diagnoses that included skin cancer and chronic kidney disease. A physician's orders dated June 26, 2024, directed staff to apply a dressing to the resident's chest wound site two times per day. On September 12, 2024, the physician's order was changed to a daily dressing change. A review of the August and September 2024 Treatment Administration Records (TAR) revealed that there was no evidence the treatment was done or refused in the morning of August 3, 2024, and in the evening of September 5, 2024. […]

• No harm, potential for more than minimal, isolatedF689Sep 20, 2024

  Based on clinical record review, observations, and staff interview, it was determined that the facility failed to adequately supervise residents while eating who were at risk for choking and eating non-edible items for two of 19 sampled residents. (Residents 25, 235) Findings include: Clinical record review revealed that Resident 25 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, dementia, dysphagia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had severe cognitive impairment and required supervision for meals. […]

• No harm, potential for more than minimal, isolatedF842Sep 20, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to maintain clinical records that were accurate and complete for one of 19 sampled residents. (Residents 22) Findings include: Clinical record review revealed that Resident 22 had diagnoses that included heart disease and hypertension. A physician's order dated August 16, 2024, directed staff to administer a blood pressure medication (propranolol) one time a day and staff was to hold the medication if the resident's systolic blood pressure was less than 130 millimeters of mercury (mmHg). In an interview on September 18, 2024, at 11:00 a.m. Resident 22 stated that staff frequently gave her blood pressure medication when her blood pressure was outside of the set parameters. […]

• No harm, potential for more than minimal, isolatedF690Mar 14, 2024

  Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one of five sampled residents. (Resident CL1) Findings include: Review of the facility policy entitled, Resident Bladder/Bowel Program, last reviewed April 28, 2023, revealed that facility staff was to complete an incontinence assessment within seven days of admission using the admission nursing assessment, incontinence risk assessment, and a three day bowel/bladder pattern record. […]

• No harm, potential for more than minimal, isolatedF580Oct 20, 2023

  Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's responsible party of a change in condition for one of 18 sampled residents. (Resident 17) Findings include: Clinical record review revealed that Resident 17 had diagnoses that included diabetes, obesity, and anemia. The Minimum Data Set assessment dated [DATE], indicated the resident was alert with confusion, and required extensive assistance from staff. Review of a nurse's note dated August 18, 2023, revealed the resident developed an open wound on the sacrum. There was no documented evidence that the facility notified the resident's responsible party of the change in the resident's medical status regarding the open wound until August 28, 2023. […]