Alta View Post Acute

In the surveyor’s words

From the most serious findings on record at Alta View Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jun 10, 2022

  Based on observation, interview, and record review, the facility failed to provide required care and services according to current standards of practice by failing to ensure multiple licensed staff, including Licensed Vocational Nurses 1, 7 and 8 (LVN) measured blood sugar levels according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice of failing to check blood sugar levels as required by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, patternF760Jun 10, 2022

  Based on observation, interview, and record review, the facility failed to ensure licensed staff, including Licensed Vocational Nurse 1, 7 and 8 (LVN) measured blood sugar levels prior to administering insulin (a medication used to lower blood sugar) to seven of 11 sampled residents (Residents 1, 2, 3, 4, 5, 6 and 7) receiving sliding scale insulin (dose of insulin dependent on blood sugar readings taken immediately before administration) between 1/1/ and 3/31/2022. The deficient practice of administering insulin without first checking blood sugar levels could have caused Resident 1 -7's blood sugar levels to drop dangerously low likely leading to hospitalization or death. […]

• Immediate jeopardy, patternF686May 13, 2021

  Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to maintain skin integrity for four of seven sampled residents (Resident 1, Resident 2, Resident 3, and Resident 7) by failing to: 1. Implement pressure injury interventions for Resident 1 admitted with stage 1 (redness, maybe painful intact skin injury) to the sacrococcyx (lower back and tail bone) area, and prevent the progression from stage 1 on 11/22/2020 to stage 4 (injury extending beyond the fatty tissue and into muscles, tendons and ligaments) on 12/3/2020, a progression of pressure injury in 11 days. This deficient practice resulted in the progression of pressure injury for Resident 1. 2. […]

• Immediate jeopardy, isolatedF689Nov 17, 2023

  Based on observation, interview, and record review, the facility failed to provide a safe environment and supervision for one of three sampled residents (Resident 1), who was at risk for elopement (leaving facility without notice or permission, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave), at risk for wandering (occurs when a person with loss of memory, thinking or reasoning roams around and becomes lost or confused about their location), and had diagnoses of epilepsy (a brain disorder that can cause people to suddenly have a seizure), to address the resident's attempt of elopement on 11/11/2023 at 1:05 PM. […]

• Immediate jeopardy, isolatedF684Oct 22, 2023

  Based on interviews and record reviews, the facility failed to provide care and services for four out of 12 Residents (22, 27, 33, and 54) in accordance with the facility's policies and procedures (P&P) titled, Nursing Care of The Resident with Diabetes Mellitus dated 2020, Condition Changes - Clinical Protocol dated 3/2023 and Nutritional assessment dated ,d+[DATE], by failing to: 1. Notify a physician if the blood sugar (BS) consistently remained above 200 milligrams per deciliter (mg/dL - unit of measurement [normal range for a diabetic according to the American Diabetes Association: 80 -130mg/dL]) for Residents 22, 27, 33, and 54. 2. Enter physician's orders for dietary consult on the medical charts for Residents 22, 27, 33, and 54. 3. […]