Alta Vista Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Alta Vista Rehabilitation and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, patternF760May 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for 1 (Resident #70) out of 7 residents reviewed for significant medication errors in that: 1. LVN H administered Potassium Chloride liquid 20 meq (milliequivalents)/15 mL (milliliters) via g-tube (gastric tube) without diluting with 4-6 ounces of water prior to administration 26 times from 03/01/23-04/25/23 2. LVN H failed to administer 5mL (milliliters) of Chlorhexidine Gluconate 0.12% solution via g-tube as ordered by physician for Resident #70 and without confirming the order with the physician prior to administering the medication 55 times from 03/03/23-04/25/23. 3. […]

• Immediate jeopardy, isolatedF580Sep 22, 2023

  Based on observation, interview, and record review the facility failed to immediately inform the resident, consult with the resident physician, and notify the resident's representative when there was a significant change in the resident's physical mental or psychological status for 1 of 5 residents (Resident #1) reviewed for notification of change of condition. The facility failed to notify the resident's physician when R#1's abnormal skin condition was identified on 09/09/23. R#1 was transferred to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. This failure could affect residents with acute ischemia by placing them at risk of delay medical treatment, hospitalization , decline in condition, and death. […]

• Immediate jeopardy, isolatedF684Sep 22, 2023

  Based on interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 (Resident #1) reviewed for quality of care. The facility failed to document, monitor, and assess Resident #1's abnormal skin discoloration for approximately 39 hours. Resident #1 was transferred to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. This failure could affect residents with acute ischemia by placing them at risk of delay medical treatment, hospitalization , decline in condition, and death. This failure resulted in an identification of Immediate Jeopardy (IJ) on 09/19/23 at 6:10 pm. […]

• Immediate jeopardy, isolatedF726Sep 22, 2023

  Based on observations, record reviews and interviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessments for one resident (Resident #1) of 5 residents reviewed for care. […]

• No harm, potential for more than minimal, patternF812Nov 19, 2025

  Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety requirements in 1 of 1 kitchen reviewed for kitchen sanitation.1. The facility failed to not store personal beverages in the food preparation area.2. The facility failed to ensure dented can were placed in a separate storage area.3. The facility failed to properly thaw raw meat that was observed in the sink designated for produce only. The raw meat was not under running water and had red liquid draining into the sinks drain.4. […]