Mira Vista Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident-identifiable information was not shared with the public for 1 of 1 sampled resident (Resident 3) reviewed for safeguarding a resident's Portable Orders for Life-Sustaining Treatment (POLST - a form designated a resident's code status and other treatment options). The facility failed to ensure Resident 3's POLST was not given to another resident's (Resident 1) family member when Resident 1 was discharged from the facility. This failure placed residents at risk for their privacy to be violated and their personal medical information being shared with an unauthorized person.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 3 halls (Residents 15,16, 18, 20, 27, 33, 43, 44, 47, 54, 64, 63, 67, 68, 70, 71, 5, 95, 94, 86) reviewed for influenza outbreak, 4 of 4 rooms reviewed for TBP (Rooms 212, 316, 213 and 115) and failed to implement their respiratory protection plan (RPP - a safety plan ensuring staff are properly trained, medically cleared, and fit-tested to wear an N95 mask) for 85 of 109 employed staff. The facility failed to ensure the staff used appropriate hand hygiene practices, staff were wearing personal protective equipment (PPE) in accordance with national standards (room [ROOM NUMBER]) and clean and disinfect universal resident medical equipment (room [ROOM NUMBER]). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the level one Pre-admission Screening and Resident Review (PASRR- assessment/a federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) were accurate, referred after expiration of an exemption, and updated for 4 of 5 residents (Residents 2, 5, 11 and 20) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurate for 7 of 7 residents (Residents 20, 32, 53, 92, 2, and 93) reviewed for certified nursing assistant (CNA) documentation, and 2 of 3 residents (Residents 92 and 53) reviewed for resident weekly skin checks. This failure included missing documentation for activities of daily living (ADLs - routine self-care such as dressing, bathing, eating, toilet, etc.), behaviors/interventions, meal consumption, voiding, and the completion of timely skin check observations which placed residents at risk for incomplete and inaccurate medical records and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide required liability notices for 3 of 3 residents (Residents 28, 101, and 102) reviewed for liability notices who remained in the facility after skilled services ended and 1 of 3 residents (Resident 28) reviewed for issuance of Notification of Medicare Non-Coverage (NOMNC) at least two calendar days prior to their Medicare services ending. These failures placed residents at risk for not being fully informed of the cost of, and/or fully understanding their Medicare benefits.

Inspectors wroteBased on interview and record review, the facility failed to initiate grievances for 2 of 4 residents (Residents 32 and 39) reviewed for grievances. The facility's failure to initiate, log, investigate verbalized concerns, and inform the residents of their findings and the actions taken, precluded the facility from identifying grievance trends and placed the residents at risk of feeling frustrated, unimportant, and with a decreased self-worth and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 5 residents (Residents 11 and 48) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure appropriate indication for psychotropic medications. This deficient practice placed residents at risk of experiencing unnecessary side effects such as sedation, decline in physical functioning, and placed residents at risk of experiencing an undignified life.

Inspectors wroteBased on record review and interview, the facility failed to provide written bed hold notice to the resident and their representative at the time of transfer to the hospital for 2 of 3 residents (Residents 53 and 92), and failed to ensure a resident hospital transfer documentation was completed as required to include the basis for hospital transfer and what specific resident needs were unable to be met by the facility for 1 of 3 residents (Resident 53) reviewed for hospitalization. These failures placed residents and their representative at risk for not having an opportunity to make informed decisions about their transfer/discharge rights, placed residents at risk with their right to hold their bed while in the hospital, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADL's) to include personal hygiene and bathing for 1 of 2 dependent residents (Resident 10), reviewed for ADLs. Facility failure to provide the residents, who were dependent on staff for assistance with grooming, placed the resident and others at risk of embarrassment, poor hygiene, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to assess, thoroughly monitor, and take timely action in accordance with professional standards of practice for 1 of 3 residents (Resident 92) reviewed for non-pressure wounds, and 1 of 1 hospice residents (Resident 11) reviewed for hospice services. Failure to ensure Resident 92's left thigh wound was assessed and measured to ensure the wound was healing and no further medical interventions were required, the failure to implement a change in Resident 11's blood pressure medications placed residents at risk for potential complications in wound healing going undetected, and risk for continued low blood pressures, and a decreased or diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 10) received the necessary care and services to prevent significant and severe weight loss within the first 60 days of admission. This failed practice caused potential harm for Resident 10 in the form of severe weight loss and placed the resident and others at risk for adverse health, safety and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual Certified Nursing Assistant (CNA) performance reviews were completed timely for 2 of 4 employees (Staff J and O) reviewed who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of the CNAs and the quality of care provided to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing information postings were current, accurate, and included the census/number of residents in the facility. These failures placed residents and visitors at risk for not being fully informed of current nurse staffing levels and resident census information.

Inspectors wroteBased on observation and interview the facility failed to ensure 1 of 4 medication carts and 1 of 2 treatment carts on 2 of 3 halls had unsecured medications. These failures placed residents at risk for unauthorized access to medications and biologicals, and potential drug misuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain and provide routine dental services for 1 of 2 sampled residents (Resident 39) reviewed for dental services. This failure placed residents at risk for continued dental problems, difficulty chewing, associated health complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure the responsible party was immediately notified and failed to update the physician timely when there was a change in condition for 1 of 3 residents (Resident 1) reviewed for hospitalization. This failure placed the resident at risk of receiving less than optimum care.

Inspectors wrote<RESIDENT 261> Resident 261 admitted to the facility on [DATE] with diagnoses which included recent norovirus (a contagious gastrointestinal virus spread by contact) infection and Clostridium Difficile infection (a contagious gastrointestinal toxin spread by contact). Both Norovirus and Clostridium difficile organisms required enteric precautions of soap and water hand hygiene; alcohol hand sanitizer does not kill those organisms. According to regulation based on Centers for Disease Control and Prevention standards, contact precautions require the staff to put on personal protective equipment (PPE) before entering the room, which included gowning and gloving, to perform hand hygiene that is appropriate to the organism, and require the facility to post signage to communicate the required level of precautions for staff and visitors. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure 2 of 6 residents (Residents 50, and 214) reviewed for unnecessary medications received medication specific monitoring. This failure placed residents at risk for unrecognized effects and/or side effects of high-risk medications.

Inspectors wrote<RESIDENT 31> Resident 31 was admitted to the facility on [DATE] with diagnoses to include CHF and HTN. Review of Resident 31's MAR for June 2025 showed the following order: - Carvedilol tablet 6.25 mg, give one tablet by mouth two times daily for HTN. Hold for HR <55 or SBP <100. There was no documentation indicating that BP or HR had been monitored prior to administering eight of eleven doses per physician orders. Review of Resident 31's clinical record vital signs with a print date of 06/06/2025, showed no documented BP or HR for the eight of the eleven doses of the Carvedilol given in June 2025. The documentation for the vital signs included: - On 06/01/2025, BP and HR were documented once. - On 06/04/2025, BP and HR were documented once. - On 06/05/2025, BP and HR were documented once. [...]

Inspectors wroteBased on observation and interviews, the facility failed to prepare food under safe and sanitary conditions in the facility kitchen. The failure to ensure hand hygiene when changing gloves and staff not wearing beard nets placed residents at risk for food contamination and foodborne illnesses.

Inspectors wrote<RESIDENT 40> Resident 40 was initially admitted to the facility on [DATE], was hospitalized then re-admitted on [DATE] with diagnoses to include depression and anxiety. In a record review on 06/04/2025, Resident 40's electronic chart showed two PASSR's. The first PASSR was dated 05/05/2024, with an evaluation done on 07/20/2024 and did not identify any issues. The second PASSR was dated 08/19/2024, and was marked evaluation required for significant change. There were no evaluations for significant change documented in resident's electronic chart. Review of Resident 40's progress notes with a print date of 06/03/2025, documented there were no notes regarding the 08/19/2024 PASSR. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a grievance was identified as an allegation of abuse or neglect for 1 of 3 residents (Resident 1) reviewed for care concern related grievances. The facility failed to ensure an allegation of abuse/neglect was identified when Resident 1 reported being left alone in their transport wheelchair for 6 hours and had become extremely sore, and 1 of 5 staff (Staff D) reviewed for annual abuse and neglect training had been completed within 12 months. These failures placed all residents at risk for abuse/neglect, psychosocial harm, physical harm, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was completed for 1 of 3 residents (Resident 1) reviewed for care concern related grievances. The facility failed to ensure an allegation of abuse/neglect was investigated which placed all residents at risk for abuse/neglect, psychosocial harm, physical discomfort and a decreased quality of life.

Inspectors wroteBush, Kally L. Based on interview and record review, the facility failed to coordinate, and schedule ordered/recommended medical appointments and a procedure for 1 of 4 residents (Resident 1) reviewed for coordination of care. This failure to implement recommendations/orders placed residents at risk for discomfort, experiencing health complications and diminished qualify of life.

Inspectors wroteBased on interview and record review the facility failed to ensure their policy related to foods brought in from outside sources included how the facility would safely store those foods and the manner in which it would ensure they were stored in a way that was either separate or easily distinguishable from facility food. This failure placed residents at risk for decreased quality of life related to an inability to exercise their right and preference to have food items of their choice brought into the facility and safely stored.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment was clean, comfortable and homelike on 3 of 3 units observed. Stained carpets, broken blinds, damaged walls and dirty floors placed residents at risk of diminished quality of life.

Inspectors wroteBased on observation and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 1-unit refrigerators. The failure to ensure the kitchen was free from potential contaminants, the maintenance to ensure the kitchen refrigerator, freezer and unit refrigerators were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included . <KITCHEN> REFRIGERATOR During an observation on 07/18/2024 at 9:15 AM, the walk-in refrigerator was observed with a broken door seal, and the temperature was 45 degrees Fahrenheit (F). The temperature log taped to the front of the door on the refrigerator showed the temperature was documented at 38 degrees F on 7/18/2024 with no time. [...]

Inspectors wroteBased on interview, observation and record review the facility failed to ensure resident preferences for food were obtained and honored for 2 of 2 residents (Resident 28 and 43) reviewed for choices. The facility's refusal to allow residents to store personal foods in the facility refrigerators resulted in Resident 43 having limited ability to enjoy food items of their choosing and failure for Resident 28 to obtain dietary preferences. These failures placed residents at risk for decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain and/or offer assistance to residents and/or their representatives to formulate Advance Directives (AD) for 2 of 6 residents (Resident 26 and 28) reviewed for ADs. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADL) to include meal assistance, personal hygiene and bathing for 3 of 6 dependent resident's (11, 28 and 33), reviewed for ADL's. Facility failure to provide the resident's, who were dependent on staff for assistance with eating, bed mobility, hygiene including oral care, and showers placed residents at risk for weight loss, pressure ulcers, embarrassment, poor hygiene, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to identify the risk of sun exposure, adequately supervise and initiate interventions to avoid a sunburn for 1 of 1 resident (Resident 26) reviewed for accidents. Resident 1 sustained a first-degree sunburn to their forehead and arms when they left the faciity on an outing. This failure placed the resident at risk for a more severe sunburn, pain and decreased quality of life. Findings Included . Resident 26 admitted to the facility on [DATE] with diagnoses that include stroke, high blood pressure, and peripheral vascular disease (narrowing of blood vessels). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow accepted infection control practices during the provision of catheter care and management for 2 of 4 residents (Residents 43 and 222) reviewed for urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag). This failure placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to resolve resident grievances for 1 of 1 sampled resident (Resident 1) reviewed for grievances. The failure to resolve resident grievances placed residents at risk for unresolved missing personal property.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer discharge notice for 1 of 3 sampled residents (Resident 1) who discharged to a hospital and refused to allow the resident to return (re-admit) back to the facility. In addition, the facility failed to notify the Office of the State Long-Term Care Ombudsman of Resident 1's discharge. This failed practice placed residents at risk of not knowing their appeal rights, risk of not having advocacy and risk of a diminished quality of life when not permitted to return to a facility in the community where their support system resided.

Inspectors wroteBased on interview, and record review, the facility failed to provide a bed hold notice in writing at the time of a resident transfer to the hospital or within 24 hours of transfer to the hospital for 1 of 3 residents (Resident 1) reviewed for hospitalizations. This failed practice placed residents or their representative at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders to obtain a hospice referral for 1 of 1 resident (Resident 2) reviewed for change in condition. This failed practice placed the resident at risk of not receiving their hospice benefit for end-of-life support for both Resident 2 and their spouse.

Inspectors wroteBased on interview, and record review the facility failed to provide timely pain management for 1 of 3 sampled residents (Resident 1) reviewed for pain management. This failed practice resulted in increased pain to Resident 1 on 02/05/2024, when they were not provided pain medication per the physician orders and placed all residents at risk of the potential for poor pain management and a diminished quality of life.