Resident #455, admitted with end-stage heart failure and anemia, had been placed under hospice care in late May. On June 4, hospice providers ordered potassium chloride extended release tablets to treat the patient's low potassium levels — a potentially dangerous condition for someone with severe heart disease.
But the order never made it to the patient.
The Licensed Practical Nurse assigned to Resident #455 told inspectors on June 12 that staff learned about hospice care plans by reviewing the resident's hospice binder or speaking directly with hospice staff during visits. When the nurse located the patient's hospice binder, it contained no plan of care, no orders, and no communication between hospice and facility staff. The nurse denied that hospice staff had ever communicated about Resident #455.
Meanwhile, the prescribed medication sat unused in the facility's medication cart. The bubble pack showed no missing doses — because none had been given.
The breakdown revealed a system where critical medical orders could vanish without anyone noticing. A scanned copy of the June 4 hospice order existed in the patient's electronic record, but the facility's order review system showed no trace of the potassium prescription. No one had entered it into the medication administration record. No nurse had been alerted to give it.
Director of Nursing explained the facility's process: when hospice sent new orders, the resident's nurse was supposed to notify the facility physician, get approval, then enter the order into the electronic medical record by the end of the shift. The expectation was clear.
The execution was not.
During the inspection interview, the Director of Nursing reviewed Resident #455's clinical record and confirmed the facility lacked any documented evidence that the potassium order had been communicated to the facility physician, that the physician had agreed with the order, or that anyone had entered it into the system so it would appear on the medication schedule.
Only when inspectors discovered the problem did staff act. At 12:18 PM on June 12, the Director of Nursing called the facility physician, who provided a telephone order to start the potassium chloride per the original hospice order. The Director then entered the order into the electronic system — eight days after hospice had prescribed it.
The Unit Manager confirmed the medication "had not been administered as ordered" and said faxes from hospice typically came directly to the nurses' station so staff could review and enter new orders appropriately. But the Unit Manager made clear they would not be checking residents' scanned documents after each hospice visit to hunt for missed orders.
The facility's 2019 hospice services agreement specified that nursing facility staff were responsible for "obtaining hospice medication information specific to each resident" and coordinating "hospice physician and attending physician orders." The document assigned clear accountability that no one had followed.
The medication mix-up represented just one of several safety breakdowns inspectors documented during their June visit.
In another incident, a Licensed Practical Nurse violated infection control protocols while caring for a patient with a feeding tube. Resident #109 had been placed on Enhanced Barrier Precautions, with a sign outside the room instructing staff to wear gowns and gloves during high-contact care.
On June 10 at 10:05 AM, inspectors watched the LPN enter Resident #109's room, stop the feeding pump, and disconnect the tube feeding from the patient's jejunostomy tube. The nurse wore no gown or gloves.
Two minutes later in the hallway, the LPN acknowledged the sign indicating Enhanced Barrier Precautions and confirmed not wearing protective equipment when disconnecting the tube feeding. The nurse verbalized that gowns and gloves should be worn when providing care to the patient's feeding tube, explaining that Enhanced Barrier Precautions helped prevent infections.
The patient's care plan, initiated in January, specifically documented Enhanced Barrier Precautions related to the presence and care of the jejunostomy tube. The facility's infection control policy stated that Enhanced Barrier Precautions served as an intervention to lessen transmission of multidrug-resistant organisms and applied to residents with any indwelling medical device.
The Director of Nursing confirmed that gowns and gloves were required when providing care to feeding tubes, explaining the precautions helped prevent introducing bacteria that could cause infections in residents with indwelling medical devices.
A third major violation involved pneumonia vaccine eligibility screening. Inspectors found that 28 of 163 residents had not been properly screened for pneumococcal vaccination eligibility, with staff relying solely on age criteria while ignoring medical conditions that qualified younger patients for the vaccine.
Resident #104 exemplified the problem. The patient's record included a vaccination permission statement from May 15 documenting that the resident was "not eligible to receive a pneumococcal vaccine" because they were under 65 years old.
But Resident #104 had type 2 diabetes mellitus, a condition that makes patients eligible for pneumococcal vaccination regardless of age under CDC guidelines.
The Infection Control Preventionist explained that residents were screened using a flowchart that asked first whether the resident was 65 or older. If not, they were automatically deemed ineligible. The preventionist initially could not respond when asked about medical conditions that might qualify younger residents for vaccination.
The facility's Vice President of Clinical Services then acknowledged that conditions like diabetes and immunocompromised status made residents eligible for the vaccine even under age 65, confirming the facility was supposed to follow CDC guidelines for determining eligibility.
When the Infection Control Preventionist and Vice President reviewed Resident #104's record during the inspection, they confirmed the patient's diabetes made them eligible for pneumococcal vaccination and should have been offered the vaccine.
The 28 affected residents included patients with chronic obstructive pulmonary disease, diabetes, heart failure, chronic kidney disease, and other conditions that qualified them for vaccination under federal guidelines. All had been automatically excluded based solely on age.
The facility's own policy, adopted in February 2019, stated that all residents should be offered pneumococcal vaccines and assessed for eligibility upon admission. CDC documentation in the facility's files confirmed that adults 19 through 64 years old with certain medical conditions were eligible for pneumococcal vaccination.
These violations painted a picture of systematic gaps in clinical oversight. A hospice patient's heart medication order vanished for over a week. Infection control protocols designed to protect vulnerable residents were ignored during routine care. Nearly three dozen residents were denied potentially life-saving vaccines based on incomplete screening criteria.
Each breakdown represented a failure to follow the facility's own documented policies and procedures. In the case of Resident #455, the consequences of missing prescribed potassium supplementation for a patient with end-stage heart failure remained unknown — the medication was finally started only after federal inspectors discovered the oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alta Skilled Nursing and Rehabilitation Center from 2024-06-13 including all violations, facility responses, and corrective action plans.
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