Alta Skilled Nursing And Rehabilitation Center

F-F849

31739

Resident to Resident Abuse

Resident #83

Resident #83 was admitted to the facility on [DATE REDACTED], and readmitted [DATE REDACTED], with diagnoses including schizophrenia, unspecified, and anxiety disorder with irritability and anger.

An Incident Note dated 04/09/2024, documented a nurse had heard Resident #83 screaming and cursing while an aide had witnessed Resident #83 spit on and throw a cup with water at the resident's roommate while the roommate was lying in bed, asleep (Resident #122).

Resident #83's Care Plan dated 05/25/2020, documented the resident had the potential for disruptive behaviors, and to monitor for inappropriate language around other residents and intervene as necessary. Care Plan dated 06/08/2023, documented the resident had demonstrated verbally aggressive behaviors towards others related to schizophrenia diagnosis and to administer medications as ordered and monitor and document for side effects and effectiveness.

A physician's order dated 04/10/2024, documented Resident #83 may be discharged to behavioral health center today, when bed was available.

Resident #122

Resident #122 was admitted to the facility on [DATE REDACTED], with diagnoses including epilepsy, unspecified, and dysphagia, oropharyngeal phase.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 295077 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295077 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alta Skilled Nursing and Rehabilitation Center 555 Hammill Lane Reno, NV 89511

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 An Incident Note dated 04/09/2024, documented Resident #122 had been asleep when Resident #83 spit on and threw water on the resident. The residents were separated, and the nurse manager was informed. Plan Level of Harm - Actual harm to move Resident #122 to another room.

Residents Affected - Few A Communication Note dated 04/10/2024, documented the social worker had met with Resident #122 to follow up on the room change. The resident verbalized to the social worker the resident had slept well and, just had to get out of there, referring to the old room.

On 06/13/2024 at 10:51 AM, the DON confirmed Resident #83 had spit on and thrown a cup of water on Resident #122. The DON verbalized Resident #83 had been receiving behavior health services prior to the altercation and the facility had not been able to implement any new interventions due to Resident #83's increased behaviors; Resident #83 was transferred to a behavioral health center for additional services, and Resident #122 was moved to another room.

The facility policy titled, Abuse Prevention Program, adopted 02/01/2019, documented as part of the resident abuse prevention program, the facility would protect residents from abuse by anyone, including other residents.

FRI #NV00070898

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 295077 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295077 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alta Skilled Nursing and Rehabilitation Center 555 Hammill Lane Reno, NV 89511

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43311

Residents Affected - Few Based on observation, interview, clinical record review, and document review, the facility failed to provide protective supervision when a resident wearing a wander device followed an employee out of an alarmed exit door, the alarm system failed to work, and the resident was found wandering around in the parking lot for 1 of 1 residents investigated for elopement (Resident #411).

Findings include:

Resident #411

Resident #411 was admitted to the facility on [DATE REDACTED], and discharged on [DATE REDACTED], with diagnoses including metabolic encephalopathy, cognitive communication deficit, and need for assistance with personal care.

A Facility Reported Incident (FRI) #NV00070899 dated 04/08/2024, documented Resident #411's significant other found the resident wandering in the parking lot and brought the resident back into the facility. Video footage review showed Resident #411 had followed a Certified Nursing Assistant (CNA) out of the East exit door at 2:46 PM. The resident wore a Wanderguard device and the alarm failed to sound when the resident exited the building.

An Elopement Risk Evaluation dated 04/03/2024, documented Resident #411 was at moderate risk for wandering based on forgetfulness or had a short attention span and was a known wanderer or had a history of wandering.

A Device Enabler Evaluation dated 04/03/2024, documented Resident #411 was using a Wanderguard device. The device use reason was documented as the resident was confused, wandered around the facility, and was at risk for elopement.

Resident #411's care plan initiated on 04/03/2024, documented the following focus:

-The resident was an elopement risk/wanderer related to a history of attempts to leave the facility unattended, impaired safety awareness.

-Resident wandered aimlessly.

Resident #411's care planned interventions were as follows:

-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversations, television, books, 04/03/2024.

-One on one supervision until Wanderguard obtained, 04/03/2024

-Place Wanderguard to alert staff of Resident's attempts to exit the building, 04/08/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 295077 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295077 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alta Skilled Nursing and Rehabilitation Center 555 Hammill Lane Reno, NV 89511

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 -Wander Alert: Left wrist, 04/08/2024

Level of Harm - Minimal harm or -Provide a photograph of the Resident to the Wanderer's List. There should be a binder for each Nurses' potential for actual harm Station and the Front Entrance, 04/03/2024.

Residents Affected - Few -When resident needed assistance back to his/her unit, staff had to physically escort him/her. Residents with Dementia were unable to follow complicated directions, 04/03/2024.

On 06/11/2024 at 2:02 PM, the DON explained all staff were trained on elopement annually and with in-services. The DON communicated the expectation of the staff to be able to distinguish which residents were safe to go outside of the building. All staff were to ensure residents did not follow the staff out of an exit door and would be expected to re-direct the resident, get the resident to a safe place, and report the situation to a nurse. The DON confirmed the elopement was preventable.

On 06/11/2024 at 2:45 PM, the Administrator explained Resident #411 was found in the East parking lot by their family member on 04/08/2024, at approximately 2:46 PM. The Administrator confirmed Resident #411 had followed an employee out of the East exit door and was wearing a Wanderguard device that did not sound the exit alarm. The Administrator explained the investigation revealed all of the alarmed exits had malfunctioned with the Wanderguard devices and did not alarm when a resident wearing the device walked past.

The Administrator explained Maintenance was responsible to check the alarm device system weekly but had not found the system was malfunctioning at every exit. The Administrator communicated the exit alarm system was replaced to correct the malfunctioning system.

The facility policy titled, Wandering and Elopements, adopted 02/01/2019, documented the facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. If an employee observed a resident leave the premises, the employee would: attempt to prevent the resident from leaving in a courteous manner, get help from another staff member in

the immediate vicinity, and instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident was attempting to leave or has left the premises.

FRI #NV00070899

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 295077