Deficiency Records for Alta Skilled Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Alta Skilled Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-12 | 2023-10-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-07-12 | 2023-10-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-07-12 | 2023-10-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-12 | 2023-10-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-12 | 2023-10-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-12 | 2023-10-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-12 | 2023-10-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-12 | 2023-10-05 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-07-12 | 2023-10-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-12 | 2023-10-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-07-12 | 2023-10-05 | N |
| Meet other general requirements. | Fire Safety | 2023-07-12 | 2023-10-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-12 | 2023-09-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-07-24 | 2023-09-13 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-24 | 2023-09-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-24 | 2023-09-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-24 | 2023-09-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-24 | 2023-08-23 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-24 | 2023-08-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-24 | 2023-08-23 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-07-24 | 2023-08-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-24 | 2023-08-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-24 | 2023-08-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-24 | 2023-08-23 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-24 | 2023-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-07-24 | 2023-08-23 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-07-24 | 2023-08-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-07-24 | 2023-08-23 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-24 | 2023-08-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-24 | 2023-08-23 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2023-07-24 | 2023-08-23 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2023-07-24 | 2023-08-23 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-07-24 | 2023-08-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-31 | 2023-06-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-31 | 2023-06-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-31 | 2023-06-26 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-31 | 2023-06-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-31 | 2023-06-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-14 | 2023-03-20 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-02-14 | 2023-03-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-14 | 2023-03-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-14 | 2023-03-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-23 | 2022-12-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-23 | 2022-12-23 | Y |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2022-11-23 | 2022-12-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-23 | 2022-12-23 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-23 | 2022-12-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-23 | 2022-12-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-23 | 2022-12-04 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-01 | 2022-10-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-01 | 2022-10-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-01 | 2022-10-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-01 | 2022-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-01 | 2022-10-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-01 | 2022-10-14 | N |
| Provide activities to meet all resident's needs. | Health | 2022-09-01 | 2022-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-01 | 2022-10-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-01 | 2022-10-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-01 | 2022-10-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-09-01 | 2022-10-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-01 | 2022-10-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-01 | 2022-10-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-01 | 2022-10-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-01 | 2022-10-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-01 | 2022-10-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-01 | 2022-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-01 | 2022-10-14 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-01 | 2022-10-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-09-01 | 2022-09-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-07 | 2022-07-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-07 | 2022-07-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-07 | 2022-07-08 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-06-07 | 2022-07-08 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-07 | 2022-07-08 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-06-07 | 2022-07-08 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-10 | 2021-11-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-10 | 2021-11-04 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-09-10 | 2021-10-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-09-10 | 2021-10-04 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-09-10 | 2021-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-10 | 2021-10-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-10 | 2021-10-02 | N |
| Report COVID19 data to residents and families. | Health | 2021-08-24 | 2021-09-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-02 | 2021-09-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-02 | 2021-09-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-02 | 2021-09-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-02 | 2021-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-02 | 2021-09-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-02 | 2021-09-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-09-01 | Not Fixed | N |
