Mira Vista Court

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents fed by enteral means received the appropriate treatment to prevent complications of enteral feeding including aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 9 residents (Resident #1) reviewed for enteral feed care. The facility failed to ensure Resident #1's tube feeding was paused when the head of his bed was lowered for incontinence care. This failure could place residents at risk for aspiration of their feeding solution.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 5 residents (Resident #1) reviewed for infection control. CNA H and CNA I failed to wear the appropriate PPE for a resident on Enhanced Barrier Precautions when providing care to Resident #1. This failure could place residents at risk of exposure to infections from other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 2 of 5 residents (Resident #12 and Resident #21) reviewed for ADL care. 1. The facility failed to ensure Resident #12's fingernails were cut and clean. 2. The facility failed to provide Resident #21 with personal hygiene and grooming during showers, leaving her with facial hair on her chin consisting of at least 10 strains of hair approximately an inch long as of 07/27/25. These failures could place residents at risk of not receiving hygiene care which could cause skin breakdown, a loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 3 residents (Resident #35) reviewed for enteral nutrition. The facility failed to follow Resident #35's physician orders for enteral feeding when LVN E flushed with 30 cc's of water instead of 60 cc's before and after feedings on 07/29/2025. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #38) reviewed for infection control. CNA A failed to wear a gown when providing care to Resident #38, who was on enhanced barrier precautions. This failure could place residents at risk of being infected by staff in contact with other residents with infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 3 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Hydrocodone 10/325's on 03/21/25 when LVN A diverted them. The noncompliance was identified as past noncompliance. The noncompliance began on 03/21/25 and ended on 03/22/25 . The facility had corrected the noncompliance before the abbreviated survey began. This failure could place residents at risk of misappropriation of property, missed medications and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) observed for infection control. LVN A failed to properly dispose of soiled dressings and guaze when she provided with Resident #1 with wound care. This failure could lead to cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from inappropriate touching by Resident #2 in which Resident #2 was observed to have his hand under the gown of Resident #1. The noncompliance was identified as past noncompliance that began on 12/17/24 and ended on 12/17/24. The facility had corrected the noncompliance before the investigation had begun. This failure could place residents at risk of unwanted touching by other residents and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to exercise their rights and to be treated with respect and dignity for 3 of 8 residents (Residents #1, #2, and #3,) reviewed for resident rights. CNA A failed to treat Residents #1, #2, and #3 with respect and dignity during her interactions with them. This failure could result in residents receiving medication or treatment without consent and decreased feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to exercise their rights and to be treated with respect and dignity for 1 of 3 residents (Resident #5) reviewed for resident rights. The facility failed to honor the request by Resident #5's resident appointed representative to refuse medical treatment from a Physician's Assistant. This failure could result in residents receiving medication or treatment without consent and decreased feelings of self-worth.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4, who had a Stage 4 pressure ulcer on her left lateral ankle, was provided with wound care as ordered by the physician. This failure could place residents at risk of developing infections or worsening of their wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of five residents (Residents #1) reviewed for feeding tubes. The facility failed to provide treatment for Resident #1 dressing around g-tube site was labeled 08/20/23. The g-tube site was observed on 08/23/24. These failures could place residents at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of seven residents reviewed for accidents. The facility failed to ensure staff checked on Resident #1 from 05:15 am until 07:50 am during which time she laid on the floor next to the bed. This failure could place residents at risk for serious injury and distress that could result in a decreased psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 Residents (Resident #15) reviewed for quality of care. The facility failed to follow physician orders to apply an arm sleeve, used to protect skin, on Resident #15's right arm. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of three residents (Resident #47) reviewed for contracture management. The facility failed to apply rolled wash cloths to Resident #47's left contracted hand (a permanent tightening of the muscles) for contracture management. This failure could place residents at risk for a decline in range of motion, decreased mobility, worsening of contractures and a decline in physical capabilities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment remained as free of accident hazards as is possible for 1 of 26 resident rooms reviewed for a safe environment. The facility failed to ensure Resident #53 did not have access to facility disposable razors. This failure could place residents at risk of accidents, injuries, or harming another resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #252) reviewed for enteral nutrition. The facility failed to follow Resident #252's physician orders for enteral feeding. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #38) reviewed for medication regimen review. The facility's Pharmacist Consultant recommended Residents #38's anxiety medication hydroxyzine required an additional consent form to be completed and uploaded to the resident's chart. This failure could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to maintain medical records that were complete and accurately documented for 1 (Resident #15) of 10 residents reviewed for resident records. The facility failed to accurately document Resident #15's use of arm sleeve on 05/28/24, 05/29/24 and 05/30/24 even though it was not performed. These failures could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for one (Resident #97) of three residents reviewed for urinary catheters. The facility failed to contact the physician when Resident #97 had blood in her catheter bag. This failure could affect residents with catheters by placing them at risk for the development and/or worsening of urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #90) reviewed for medication errors. LVN A failed to order antibiotics and normal saline solution prior to the facility running out, resulting in Resident #90 missing two days of antibiotic therapy. This failure could place residents at risk of their infections worsening and extending their length of stay in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and effective pest control program to keep the facility free of pest for two (Hall 200 and Hall 100) of five halls, the activity room, the dining room, and one of one kitchen. The facility failed to ensure an effective pest control program was in place to keep roaches out of the facility. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete an assessment that accurately reflected the resident's status for 2 of 9 sampled residents (Residents #1 and #3) reviewed for MDS accuracy, in that: 1. The facility failed to ensure Resident #1's MDS accurately reflected Sections: -C -Cognitive patterns memory loss, E- Behaviors, of refusing care, Section C for cognitive communication, Section I-Active diagnosis, anxiety, and psychotic behaviors. 2. The facility failed to ensure Resident #3's MDS accurately reflected Section C- cognitive pattern and functions was left blank. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for kitchen sanitation: 1. The facility failed to label, date, and seal food found in the refrigerators. 2. The facility failed to ensure all expired foods were removed from the refrigerator. These failures could place residents at risk for cross-contamination and foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received proper treatment and care to maintain good foot health for 1 (Resident #1) of 4 residents reviewed for foot care. (1) The facility failed to ensure Resident #1 who had a diagnosis of atherosclerosis of the extremities (A disease of the peripheral blood vessels characterized by narrowing and hardening of the arteries that affect blood supply to the legs and feet) (The peripheral vessels consist of the veins and arteries not in the chest or abdomen i.e., in the arms, hands, legs and feet) and peripheral vascular disease (a progressive circulation disorder that involves the narrowing, blockage, or spasms in the blood vessels as a result of arteriosclerosis) and was at risk for impaired blood flow to his feet, received assessments of his feet. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 Residents (Resident #63) reviewed for quality of care: The facility failed to ensure Resident #63 was wearing compression wraps (a specialized hosiery designed to help prevent the occurrence of and guard against further progression of venous disorders such as swelling/inflammation and blood clots) as ordered by the physician. This failure placed residents at risk of not receiving appropriate care and worsening of their conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing, prevent infection, and to prevent the development of pressure injuries for 1 (Resident #86) of 10 residents reviewed for pressure injuries. The facility failed to ensure Resident #86 was offloading (minimizing or reducing weight placed on the foot to help prevent pressure ulcers) right heel and wearing foot boot (device used to redistribute pressure across the foot). This failure placed residents at risk of not receiving appropriate care; development and worsening of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, based on a resident's comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or the resident preferences indicated otherwise recognize, evaluate, and address the needs of for two (Resident #31 and #83) reviewed for nutrition. 1. The facility failed to put measures in place for Resident #31 after he went three days without eating breakfast and lunch. 2. The facility failed to provide Resident #83 with Ensure and Super Pudding three times a day as ordered by the physician. These failures could placed the residents at risk of weight loss, and a decline in their physical condition.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs of each resident for two of three residents (Residents #39 and #11) reviewed for pharmacy services. MA A failed to follow the facility's policy, which reflected crushed medications should be administered individually, when she administered crushed medications to Resident #39 and Resident #11. These failures could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response to their medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for one of two staff (MA A) which resulted in a 6.8% medication error rate after 29 opportunities with 2 errors for two of three residents (Residents #39 and #11) reviewed for medications. MA A failed to follow the physician orders of do not crush for ferrous sulfate 325 mg for Resident#39 and myrbetriq 25 mg extended release for Resident #11. These failures could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response to their medications.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of two medications storage refrigerators (300/400 Halls refrigerator) reviewed for medication storage. The facility failed to ensure the temperatures for the medication refrigerators for 300/400 halls were being checked and documented to ensure drugs and biologicals stored in the refrigerators were at the proper temperatures. This failure could place residents at risk of receiving medications that were ineffective due to improper temperature control.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 2 of 10 residents (Residents #63 and #86) whose records were reviewed. The facility failed to accurately document Resident #63's use of compression wraps on 03/28/23, 03/29/23 and 03/30/23 even though it was not performed. The facility failed to accurately document Resident #86's was offloading right heel and wearing foot boot on 03/28/23, 03/29/23 and 03/30/23 even though it was not performed. These failures could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care.