Every finding on record at Alpine Valley Post Acute and Healthcare Center

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. On September 17, 2024, at 11:35 a.m., observation of Resident 60 revealed his chest wound did not have a dressing covering it, and small amounts of yellow and red drainage could be seen seeping through his white shirt. On September 17, 2024, at 1:01 p.m., in an interview with Licensed Practical Nurse 1, it was confirmed that there was no dressing on the wound. In an interview on September 20, 2024, at 11:48 a.m., the Director of Nursing confirmed that a dressing should have been on the wound, and the dressing should have been changed, as ordered. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

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. Review of the care plan revealed the resident was at risk for nutritional problems related to his dementia and dysphagia and staff was to observe for signs and symptoms of dysphagia, such as, choking, pocketing food in his mouth, coughing, etc Review of an incident report dated June 9, 2024, revealed that the resident had a choking episode that required mechanical assistance from staff. A progress note dated June 13, 2024, from the registered dietitian noted that Resident 25 was to eat his meals in the dining room with staff supervision. Observations on September 17, 2024, from 12:30 p.m. to 1:00 p.m., September 18, 2024, from 12:40 p.m. to 1:05 p.m., and September 19, 2024, from 12:40 p.m. to 1:08 p.m., revealed that the resident was eating lunch in his room with no supervision. Clinical record review revealed that Resident 235 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease and a cognitive communication deficit. Review of the MDS assessment dated [DATE], revealed that the resident had severe cognitive impairment and required supervision for meals. Review of a nursing admission noted dated September 3, 2024, revealed that the resident had pica (a mental health condition where a person compulsively eats things that are not food). Review of the care plan revealed the resident was at risk for nutritional problems related to a history of pica and staff was to observe for signs or symptoms of dysphagia. Observations on September 17, 2024, from 12:30 p.m. to 1:00 p.m., September 18, 2024, from 12:40 p.m. to 1:05 p.m., and September 19, 2024, from 12:40 p.m. to 1:08 p.m., revealed that the resident was eating lunch in her room with no supervision. In an interview on September 20, 2024, at 12:05 p.m., the Administrator confirmed that the residents should have been supervised with all meals. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

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. A review of Resident 22's medication administration records for August and September 2024 revealed that staff documented that they administered the blood pressure medication nine times when her blood pressure was less than 130 mmHg. In an interview on September 20, 2024, at 11:25 a.m., the administrator confirmed that staff did not properly document that the medication was held when Resident 22's blood pressure was below the ordered parameters in the clinical record. 28 Pa. Code 211.5(f) Medical records.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's representative(s) of transfer and the reasons for the move in writing for two of five sampled residents who were transferred to the hospital. (Residents 29, 83) Findings include: Clinical record review revealed that Resident 29 was transferred and admitted to the hospital on July 28, 2024, after a change in condition. There was no evidence that the resident's responsible party was provided with written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 83 was transferred and admitted to the hospital on June 28, 2024, after a change in condition. There was no evidence that the resident's responsible party was provided with written information regarding the resident's transfer to the hospital. In an interview on September 20, 2024, at 11:30 a.m., the Administrator confirmed that written transfer information, including the reasons for the move, was not provided to residents' representatives.

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. After completion of the bladder/bowel incontinence assessment and the three day bowel/bladder pattern record, an assessment would be completed to determine if there was a pattern present, what type of incontinence, and then determine which incontinence program would be appropriate. The program was to be documented on the care plan. Clinical record review revealed that Resident CL1 was admitted to the facility on [DATE], with diagnoses that included dementia and hypertension. According to the Minimum Data Set assessment, dated February 10, 2024, the resident needed assistance from staff for toileting. The assessment further indicated that the resident was incontinent of urine and was not on a toileting program. Review of the current care plan revealed that Resident CL1's type of urinary incontinence was not identified and there were no specific interventions developed to address CL1's urinary incontinence. There was no documented evidence that an incontinence risk assessment, and an assessment to determine the type of incontinence and an appropriate incontinence program were ever completed. In an interview on March 14, 2024, at 1:52 p.m., the Nursing Home Administrator confirmed that there was no documented evidence that Resident CL1's urinary incontinence had been assessed per facility policy. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

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. In an interview on October 20, 2023, at 12:20 p.m., the Administrator confirmed that there was no documented evidence that the resident's responsible party had been notified of the change in condition. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to ensure that each resident was administered medication as prescribed by the physician for one of 18 sampled residents. (Resident 77) Findings include: Clinical record review revealed that Resident 77 had diagnoses that included anxiety disorder, depression, and dementia. On August 25, 2023, the physician ordered for staff to apply ABHR (a combination of Ativan, Benadryl, Haldol, and Reglan) gel every four hours. Review of the medication administration records for August and September 2023, revealed that the resident had not received the scheduled doses of the medication 25 times in August 2023, and 19 times in September 2023. Review of nursing documentation revealed that the medication was not delivered from the pharmacy August 25, through 29, 2023, and September 17, through 20, 2023. In an interview on October 20, 2023, the Nursing Home Administrator confirmed that Resident 77's medication had not been delivered by the pharmacy on the above-mentioned dates. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, it was determined that the facility failed to notify a representative of the Office of the State Long Term Care Ombudsman of resident transfers for five of six residents sampled who were transferred to the hospital. (Residents 4, 14, 47, 70, 77) Findings include: Clinical record review revealed that Resident 4 was transferred and admitted to the hospital on August 24 and September 10, 2023, after changes in condition. There was no documented evidence that notification was sent to the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 14 was transferred and admitted to the hospital on August 23, 2023, after a change in condition. There was no documented evidence that notification was sent to the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 47 was transferred and admitted to the hospital on July 7, 2023, after a change in condition. There was no documented evidence that notification was sent to the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 70 was transferred and admitted to the hospital on July 7 and August 22, 2023, after changes in condition. There was no documented evidence that notification was sent to the Office of the State Long Term Care Ombudsman. Clinical record review revealed that Resident 77 was transferred and admitted to the hospital on August 18, 2023, after a change in condition. There was no documented evidence that notification was sent to the Office of the State Long Term Care Ombudsman. In an interview on October 20, 2023, at 11:30 a.m., the Nursing Home Administrator confirmed that the facility had not contacted the Office of the State Long Term Care Ombudsman for the above-mentioned resident transfers. 28 Pa Code 201.14(a) Responsibility of licensee.

Based on clinical record review and staff interview it was determined that the facility failed to ensure that physician's orders were implemented for one of four sampled residents. (Resident CL1) Findings include: Clinical record review revealed that Resident CL1 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure, hypertension, and atrial fibrillation. On November 6, 2022, the physician ordered for staff to notify her if the resident's systolic blood pressure was greater than 180 or less than 100 mm/Hg (millimeters of mercury). A review of the resident's blood pressures for November and December 2022, revealed that on November 9, 12, and December 5, 2022, CL1's systolic blood pressure was less than 100 mm/Hg. There was no documented evidence that the physician was notified of CL1's systolic blood pressures that were less than 100 mm/Hg. In an interview on February 9, 2023, the Nursing Home Administrator stated that there was no documented evidence that the physician was notified of the resident's systolic blood pressures on November 9, 12, and December 5, 2022. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement interventions to prevent contractures for one of 18 sampled residents. (Resident 37) Findings include: Clinical record review revealed that Resident 37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE], revealed that the resident had cognitive impairments, required extensive assistance from staff with bed mobility and dressing, and had functional limitations in range of motion. Review of the current care plan revealed an intervention dated July 23, 2021, for staff to complete passive range of motion to the resident's arms twice a day. There was no documented evidence that the range of motion program was completed as care planned. In an interview on December 12, 2021, at 10:15 a.m., the Nursing Home Administrator confirmed that there was no documented evidence that Resident 37's range of motion was completed as care planned. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement care plan interventions in response to a resident with a history of behaviors towards staff and residents for one of two sampled residents. (Resident 58) Findings include: Clinical record revealed that Resident 58 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated (MONTH) 23, 2019, identified that the resident's cognition (the ability to make decisions) was severly impaired, including the inability to make decisions without staff assistance. During that review period, it was noted Resdient 58 exhibited behavioral symptoms directed towards staff and other residents. The ongoing care plan dated (MONTH) 25, (YEAR), identified that the resident had the potential to be physically aggressive/combative related to his cognitive impairment. Interventions included be conscious of Resident 58's personal space-inform resident verbally before touching/providing care and provide space when resident is attempting to shake others resident's hands. On (MONTH) 4, 2019, it was noted in the clinical record that Resident 58 had increased agitation in the morning during medication administration and hit the nurse administering the medication on the chin with a closed fist. Behaviors continued throughout the shift. The resident was noted to occasionally pound on the the table and wheelchair with his arms. He was also reaching and leaning towards other residents as they passed by. On (MONTH) 19, 2019, Resident 58 was sitting in his wheelchair when another resident was walking past. He extended his arm out and make contact with the resident. On (MONTH) 21, 2019, it was noted that the interdisciplinary team reviewed the incident that occurred on (MONTH) 19, 2019, and requested activities to evaluate for diversional activities. On (MONTH) 21, 2019, a quaterly activities assessment was completed; however, there was no indication that diversion activities were developed, or implemented. Additionally, it was noted that interventions/approached have been effective in reaching goals. On (MONTH) 7, 2019, Resident 58 was observed in contact with another resident requiring staff to intervene. On (MONTH) 10, 2019, it was noted in the clinical record that Resident 58 continued to have increased unpredictable behavior towards residents and staff. In an interview on (MONTH) 7, 2019, the Director of Nursing confirmed that care plan approached were not effective preventing, or redirecting the resident behaviors. 28 Pa. code 211.10(d) Resident care policies. Previously cited 7/27/18 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/22/17, 10/11/17

Based on observation, clinical record review and staff interview, it was determined that the facility failed to review the risks and benefits of use of enabler bars/side rails with a resident or their representative and obtain informed consent for enablers bars/siderails prior to use for one of 31 sampled residents (Resident 77). Findings include: Clinical record review revealed that Resident 77 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. An admission fall assessment identified that the resident was at risk to fall due to decreased mobility and the need for two staff to assist with transfers. Occupational therapy progress notes from (MONTH) 28, through (MONTH) 8, (YEAR), identified that the resident utilized bed mobility bars (enabler bars/siderails) for bed mobility. Observations on (MONTH) 24, (YEAR), at 12:44 p.m. and (MONTH) 26, (YEAR), at 11:13 a.m. revealed bilateral mobility bars attached to Resident 77's bed. There was no evidence to support a discussion of the risk versus benefits with consent was obtained from the resident or representative for the use of the bed mobility bars. In an interview on (MONTH) 27, (YEAR), at 11:27 a.m., the Administrator stated that the facility had no evidence to support a discussion of the risks versus benefit with consent was obtained prior to use of the bed mobility bars for Resident 77.

Based on clinical record review, policy review, observations and staff interview, it was determined that the facility failed to ensure that infection control practices were implemented to reduce the potential spread of infection for one of two residents on transmission based precautions out of a sample of 31 residents (Resident 147). Findings include: Review of the facility's Transmission Based Precautions policy last reviewed on (MONTH) 19, (YEAR), revealed that residents being treated for [REDACTED]. The policy directed staff to wear gloves when entering the room and immediately wash their hands before leaving the room of a resident on contact precautions for [MEDICAL CONDITION]. Clinical record review revealed that Resident 147 was admitted to the facility on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. Ongoing physician orders [REDACTED]. On (MONTH) 24, (YEAR), at 11:02 a.m. a physical therapist (Employee 1) provided treatment to Resident 147 in the resident's room. Employee 1 came into contact with the resident's walker and resident care equipment (pulse oximeter). Employee 1 failed to wear gloves while providing care to the resident and failed to immediately wash their hands when leaving the resident's room. In an interview on (MONTH) 26, (YEAR), at 10:26 a.m. the facility's Infection Control Nurse stated that Resident 147 was on contact precautions and Employee 1 should have worn gloves when entering the room to care for Resident 147 and immediately washed her hands prior to leaving the room. 28 Pa. code 211.10(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 6/22/17, 10/11/17

Based on clinical record review, resident interview, staff interview and a review of facility documentation, it was determined that the facility failed to respond to resident's request for assistance in a timely manor to enhance each resident's quality of life for two of eight sampled residents. (Residents R , R ) Findings include: Clinical record review revealed that Resident R had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], identified that the resident had no memory impairment and was dependent on staff to transfer between surfaces and to use the toilet. The care plan dated August 30, 2017, directed staff to have the resident's call bell within her reach and to respond to her requests for assistance with activities of daily living. In an interview on October 11, 2017, at 9:55 a.m., Resident stated that she required staff assistance for toileting (utilizing a bedpan) during the overnight shift because she was not able to independently walk to the bathroom. She stated that staff often did not respond timely when she activated her call bell to utilize the bedpan taking staff from thirty minutes to an hour to respond to her request for assistance. Documentation also revealed that Resident R expressed concern in the most recent resident council meeting on September 20, 2017, regarding the lack of timely staff response to her call bell. A review of electronic records of staff response times to resident Resident R 's call bell from September 27, 2017, through October 11, 2017, revealed ten occasions when it took over ten minutes for staff to respond to the resident's request for staff assistance. On October 2, 2017, staff's response time was over twenty-three minutes (23:47) at 6:47 a.m., and on October 3, 2017, response time was over twenty-two minutes (22:37) at 3:35 a.m. Clinical record review revealed that Resident R had [DIAGNOSES REDACTED]. An MDS assessment dated [DATE], identified that the resident needed staff assistance to walk, transfer between surfaces and use the toilet. The resident's current care plan directed staff to keep the resident's call bell within her reach so she could ring her bell when she needed assistance. In an interview on October 11, 2017, at 10:02 a.m., Resident R stated that at times she waited up to one half hour for staff to respond to her call light. Review of electronic records from September 27, 2017, through October 11, 2017, revealed ten occasions when staff response times exceeded ten minutes to answer Resident R 's request for assistance. On October 3, 2017, staff response time to Resident's R call bell was recorded at over thirty-three minutes (33:41) at 6:15 a.m. In an interview on October 11, 2017, at 12:28 p.m., the Administrator stated that staff's response to residents' call bells should not exceed ten minutes. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/23/17

Based on clinical record review, observation and staff interview, it was determined that the facility failed to provide a resident with a physician prescribed therapeutic diet for one of four sampled residents who had prescribed therapeutic diets. (Resident R55) Findings include: Clinical record review revealed that Resident R55 had [DIAGNOSES REDACTED]. On April 17, 2017, a physician ordered for staff to provide the resident with a therapeutic diet that included [MEDICATION NAME] foods. Review of the current plan of care revealed that there was a problem area identified for a potential for altered nutritional status due to a history of weight fluctuations. The goal was for the resident to consume adequate nutrition and the intervention was for staff to provide the resident with enhanced foods. In an interview on June 21, 2017, at 1:11 p.m., the Director of Dietary stated that the [MEDICATION NAME] food product for lunch on a daily basis was mashed potatoes. Observation on June 21, 2017, at 12:07 p.m., revealed that the resident received her lunch; however, the resident was not served mashed potatoes which was the [MEDICATION NAME] product. In an interview on June 23, 2017, at 9:55 a.m., the Director of Nursing confirmed that the resident was to receive [MEDICATION NAME] products at meal times as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation and manufacturer's product specifications, it was determined that the facility failed to ensure that nutritional supplements were stored according to acceptable standards on one of three nursing units. (First floor) Findings include: Observations during the initial environmental tour on June 20, 2017, at 9:30 a.m. revealed that there were numerous healthshakes (three different drawers) in the refrigerator on the First floor nursing unit. Review of the manufacturer's specification on the individual product indicated that staff was to discard if not used within 14 days of the product being thawed. Dietary staff applied a sticker with the use by date. On June 20, 2017, at 9:30 a.m, at 12:20 p.m. and 1:55 p.m. there were seven healthshakes with expired use by dates or not dated at all. A dietary staff was observed at 12:20 p.m. checking the refrigerator but did not remove any expired healthshakes. On June 21, 2017, at 9:35 a.m. and 1:05 p.m., there were six healthshakes with expired use by dates. On June 22, 2017, at 10:00 a.m., there were still six healthshakes with expired use by dates.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate clinical records for two of 20 sampled residents. (Residents R21, R61) Findings include: Clinical record review revealed that Resident R21 had ongoing physician's orders [REDACTED]. Review of the weight documentation revealed that staff failed to document the resident's weight on May 12, 2017 and on June 5, 9,18, 2017. Clinical record review revealed that Resident R61 had physician's orders [REDACTED]. Review of the Medication Administration Records for May and June 2017 revealed that there was no documented weekly weights for May 8, 15, 2017, and for June 12, 19, 2017. Review of the MAR for April 2017 revealed that there was no documented blood pressure for April 17, 24, 2017. In an interview on June 23, 2017, at 10:00 a.m. the Director of Nursing confirmed that there were no weekly weights or blood pressures documented in the resident's clinical record for the aforementioned dates. 28 Pa.Code 211.5(f) Clinical records.

Based on observation, clinical record review and staff interview, it was determined that the facility failed to provide enhanced food items for five of five residents in the main dining room. (Residents R26, R28, R43, R45, R57) Findings include: Clinical record review revealed that Resident R26 had a poor appetite and received a regular enhanced diet. In an interview on June 22, 2015, at 12:20 p.m., the Dietary Manager stated that mashed potatoes was the enhanced food item for lunch. Observations of the food items on the steam table revealed only one container of mashed potatoes which was also a regular menu item for the meal. The Dietary Manager confirmed that staff had not provided the enhanced mashed potatoes in the main dining room. There were five residents (Residents R26, R28, R43, R45, R57) that did not receive the enhanced food item.

Based on clinical record review and staff interview, it was determined that the facility failed to consistently provide a restorative ambulation program for one of two sampled residents on restorative services. (Resident R28) Findings include: Clinical record review revealed that Resident R28 had [DIAGNOSES REDACTED]. The resident was discharged from physical therapy on June 1, 2015, with a recommendation for a restorative nursing program. A restorative ambulation program was started on June 5, 2015, for staff to walk the resident twice a day. Review of the daily documentation for the restorative program revealed that from June 5 to 24, 2015, staff had not offered the resident the opportunity to walk on 23 of the 40 scheduled times. In an interview on June 24, 2015, at 2:15 p.m., the Restorative Nurse confirmed that staff had not consistenly provided the walking program. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation and clinical record review, it was determined that the facility failed to provide adaptive equipment for one of three sampled residents. (Resident R13) Findings include: Clinical record review revealed that Resident R13 had [DIAGNOSES REDACTED]. On May 20, 2015, a neurologist recommended an occupational therapy consult for tremors which caused a decline in the resident's ability to safely feed himself. The Occupational Therapist discharged Resident R13 on June 5, 2015, with double handled weighted mugs with a spouted lid for all beverages. During lunch observations on June 22, 2015, the resident received four beverages but only one beverage was provided in the appropriate adaptive equipment. The three other beverages were provided in regular glasses. The resident had difficulty holding the regular glass and did experience some spillage.