Monte Vista Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to provide requested medical records within 48 hours from the written request for one of two sampled residents (Resident 1). This failure resulted in untimely access to Resident 1's medical records by Resident 1's authorized representative (Legal Services and the Family Member [FM]) and resulted in a violation of Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate medical records for one of three sampled residents (Resident 1) when Resident 1's Documentation Survey Report (DSR - certified nursing assistant's [CNA's] documentation of care provided to the resident) regarding turning and repositioning Resident 1 every two hours was not completed on 4/12/2026, 4/13/2026, 4/15/2026, 4/17/2026, 4/18/2026, and on 4/20/2026 to 4/25/2026. This failure resulted in Resident 1's medical record containing incomplete information and had the potential for Resident 1 to receive inappropriate care and treatment resulting in delayed wound healing or worsening of Resident 1's pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive person-centered care plans (CP) were developed for two of two sampled residents (Resident 36 and Resident 14) in accordance with the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered and Fall Risk Assessment. This failure had the potential to result in unmet individualized needs for Residents 36 and 14 and the potential to affect the resident's physical and psychosocial well-being. Cross Reference F689Findings: a. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of three sampled residents (Resident 20, 24, 36) received medication or treatment in accordance with the physician's orders and the facility's policy and procedures (P&P) by: A. Failing to administer two grams of lidocaine (medication used to numb tissues for procedures or pain relief) external ointment 5% as indicated on the medication physician order for Resident 20. B. Failing to provide Restorative Nurse Assistant (RNA, specialized rehabilitative care provided by nurse assistants with extra training to help residents regain or maintain mobility, strength, and independence in activities of daily living) services as indicated in Resident 24's physician order. C. Failing to initiate Fall Risk Assessments after Resident 36 sustained falls on 1/30/2026, 2/19/2026, 3/1/2026, 3/23/2026, and on 4/15/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one bag of breaded fish, in one of one freezer (Freezer 1), was labeled and dated as indicated in the facility's policy and procedure (P&P) titled, Food Receiving and Storage. This deficient practice had the potential to result in foodborne illnesses (type of illness caused by consuming contaminated food or beverages) to the residents residing at the facility and consuming the food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to ensure:a. Personal care items found inside the [NAME] and [NAME] restroom (a shared restroom situated between two bedrooms, featuring direct access from both rooms) for 4 of 7 sampled residents (Resident 54, Resident 9, Resident 39, and Resident 45) were labeled and stored properly.b. The lint screen/trap for one of one sampled commercial laundry dryer (CLD) was free of accumulation of lint c. An Enhanced Barrier Precaution (EBP - an infection-control practice to prevent the spread of bacteria in nursing homes) sign was posted outside of 1 of 7 sampled residents (Resident 70). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 44) was treated with dignity when Certified Nursing Assistant (CNA) 1 failed to close the door of Resident 44's shared room and/or the door of the shared restroom while Resident 44 was using the toilet on 4/21/2026. This deficient practice could potentially result in Resident 44 feeling bothered, invaded, or humiliated, and the potential to negatively impact Resident 44's psychosocial (the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment) well-being.

Inspectors wroteBased on interview and record review, the facility failed to create a Baseline Care Plan (BCP, a form where one can summarize a person's health conditions, care needs, and current treatments) for one of one sampled resident (Resident 70) with 48 hours of admission. This deficient practice had the potential to result in unmet needs for Resident 70.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safety measures to ensure one of four sampled residents (Resident 36) who had a history of multiple falls and was at risk for falls. On 4/24/2026 Resident 36's bed was not in the lowest position and Resident 36's bilateral (two sides) floor mats were not on Resident 36's bedside. The deficient practice had the potential to result in falls, injury, and a physical decline to Resident 36. Cross Reference F684 and F656.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 32), who was receiving enteral feeding (tube feeding), was provided appropriate treatment and services to prevent complications to Resident 32's gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings and/or medications to be administered directly to the stomach common for people with swallowing problems). On 4/23/2026, Resident 32 did not have an abdominal binder (a wide, compressive belt made of elastic or fabric that wraps around the stomach) wrapped around Resident 32's GT area, Resident 32's GT site had an undated soiled dressing (a piece of material such as a pad applied to a wound to promote healing and protect it from infection), and the GT site had redness, inflammation, and dried-up drainage around the GT site. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 14) received proper respiratory (relating to breathing) care such as oxygen (02 [a colorless, odorless, tasteless gas essential for living]) therapy in accordance with the physician's order. This deficient practice resulted in Resident 14's not receiving the correct dose of supplemental 02 and the potential to result in complications such as shortness of breath and respiratory failure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post nurse staffing information of actual hours worked by licensed and unlicensed nursing staff who were directly responsible for resident care, per shift daily, in a prominent location and make readily accessible to residents and visitors for viewing on 4/21/2026, 4/22/2026, 4/23/2026 and 4/24/2026. This deficient practice resulted in inaccurate nursing hours posted by the facility and had the potential to result in residents and family members obtaining misleading information posted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 48) had two home medication bottle contents verified by a licensed pharmacist as indicated by the facility's policy and procedure (P&P) titled, Medications Brought to the Facility by the Resident/Family. This deficient practice had the potential for Resident 48 to receive medication and/or tablets other than what was indicated on the medication bottle labels and the potential to affect Resident 48's physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) had a consent (when a patient gives permission for something to happen) for the COVID-19 (Coronavirus Disease of 2019 - a highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine (medications used to prevent diseases usually given by injection or by mouth) prior to being administered the vaccine and as indicated by the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents. This deficient practice had the potential to result in Resident 4 not making informed decisions due to not being aware of the potential risks and benefits associated with the vaccine.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (CP, a person-centered plan that outlines a resident's specific health needs, goals, and tailored interventions required to achieve their highest level of physical, mental, and psychosocial well-being) for two of three sampled residents (Residents 1 and Resident 2), as evidenced by: 1. Resident 1's vaccine (a type of medicine that helps the body to fight a disease before getting it, so illness is prevented or stays mild) refusal was not addressed in the care plan. 2. Resident 2's influenza (a highly contagious respiratory illness caused by influenza viruses that infect the nose, throat, and the lungs) status was not addressed in the care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Influenza Vaccine for one of three sampled employees (Licensed Vocational Nurse [LVN] 1) when the facility did not obtain LVN 1's influenza vaccine (an annual vaccine designed to protect against infection from influenza [a highly contagious respiratory illness caused by influenza viruses that infects the nose, throat, and the lungs] viruses) administration record to ensure tracking and documentation of employee influenza vaccination. This failure resulted in LVN 1's employee file being incomplete and had the potential for influenza transmission to vulnerable residents (in general), causing harm, and an inability to track vaccination records.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating, dated 4/2021, for one of three sampled residents (Resident 3) on 1/30/2026 by failing to report Resident 3's allegation of abuse within two hours and failing to remove Certified Nursing Assistant (CNA) 1 from resident contact immediately after Resident 3 made an allegation of abuse involving CNA 1. These deficient practices had the potential for Resident 3 to feel unsafe and for Resident 3 to be subjected to abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin for one of ten sampled residents (Resident 2) to the local Ombudsman (an official appointed to investigate individuals' complaints against facility administration), to the Police, and to the State Survey Agency within two (2) hours of obtaining Resident 2's right hip X-ray results, in accordance with facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. This failure had the potential to place Resident 2 at risk for further injury and/or harm from abuse and/or other sources.

Inspectors wroteBased on interview and record review, the facility failed to investigate an injury of unknown origin for one of ten sampled residents (Resident 2) after Resident 2's bilateral hip (involving both hips) X-ray (picture or digital image of the inside of the body) results, dated 12/21/2025 and timed at 9:14 am, indicated Resident 2 had a suspected acute right femur (thigh bone) fracture (a partial or complete break in the bone). Resident 2 was transferred and admitted to General Acute Care Hospital (GACH) 1 on 12/21/2025 at 4:44 pm. Resident 2's GACH 1 right hip X-ray results, dated 12/22/2025 and timed at 9:11 am, indicated Resident 2 had an acute right femur fracture. This failure had the potential to place Resident 2 at risk for further injury and/or harm from abuse and/or other sources.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 4 did an assessment including vital signs (VS - measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature) and documented the assessment and VS on the medical record for one of 10 sampled residents (Resident 2) before and after Resident 2 went to an outside doctor's appointment. This failure had the potential for Resident 2's change in condition to be unmonitored which could result in delayed care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were stored, prepared, and distributed under sanitary conditions for all the residents who received food from the kitchen by failing to:1. Ensure food past the use-by date was not available for use in the kitchen.2. Ensure food stored in the kitchen had an open date. These failures placed all residents who received food from the kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). During a concurrent observation and interview on 07/23/2025 at 9:15 a.m. with the Dietary Supervisor in the facility kitchen walk-in refrigerator, a clear plastic container of diced tomatoes was observed labeled with an open date of 07/16/2025. The Dietary Supervisor stated, That (diced tomatoes) should have been discarded three days after opening (7/19/2025). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two trash containers was closed with a tight-fitting lid and kept covered. This failure had the potential to attract insects and harbor pests in the refuse area that can cause a wide spread of diseases and affect the residents, staff, and visitors. During a concurrent observation and interview on 7/23/2025 at 9:17 AM with the Dietary Supervisor (DS) at the kitchen, a large white trash can was observed without a lid. The trash can was partially filled with food waste and positioned near clean food carts and meal preparation surfaces. The trash can was open to the environment and not covered in any way. The DS stated the lid of the trash container should be closed at all times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe, sanitary, and homelike environment for the following by failing to: a) One of one sampled resident's bathroom (Resident 29) did not have a clogged toilet. b) Maintain Seven of Seven resident bathrooms (Bathrooms 1, 2, 3, 4, 5, 6, and 7) affecting 18 residents (Resident 3, Resident 4, Resident 5, Resident 7, Resident 8, Resident 11, Resident 15, Resident 20, Resident 24, Resident 27, Resident 30, Resident 31, Resident 32, Resident 33, Resident 36, Resident 39, Resident 49, and Resident 211). c) Maintain Four of Four resident rooms (Rooms A, B, C and D) affecting six residents (Resident 3, Resident 4, Resident 5, Resident 8, Resident 20, and Resident 36). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of one sampled resident (Resident 25), received proper care by failing to follow Resident 25's physician's order that included parameters (specific instructions that can be measured) indicating when to hold (not give) the administration of Losartan Potassium (medication used to treat high blood pressure [hypertension]) for) as indicated in the facility's policy and procedure (P&P), titled, Administering Medications. This deficient practice could potentially result in Resident 25's blood pressure to drop too low (hypotension) and result in a medical emergency due to not enough oxygen (02 - colorless, odorless, tasteless gas essential for life) and nutrients to Resident 25's vital organs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 41 and Resident 22), were provided treatment consistent with professional standards of practice to promote the healing of Resident 41's existing pressure ulcer/injury (PI - localized, pressure related damage to the skin and/or underlying tissue usually over a bony prominence) and to prevent the development of PI to Resident 22 by failing to ensure: a. Resident 41's low air loss mattress (LAL - a mattress attached to a blower pump designed to circulate a constant flow of air to remove excess moisture and regulate the pressure levels, thereby improving blood flow to the wound site) was set correctly on 2/19/2025. b. Resident 22 was turned and repositioned in accordance with Resident 22's care plan (CP). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, three of three sampled residents (Resident 21, 52, and 111), were provided appropriate respiratory care and services in accordance with the facility's policy and procedures (P&P) by failing to ensure: a. One of three sampled resident's (Resident 21) nebulizer (a medical device that turns liquid medications into a mist, which is then inhaled through a mouthpiece or a mask) was changed timely. b. Two of three sampled resident's (Resident 52 and 111) oxygen (02 - colorless, odorless, tasteless gas essential for life) tubing and breathing treatment's humidifier (a device that adds moisture to the air to prevent dryness) were labeled with a date to ensure the equipment was changed timely. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate was not 5 percent or greater for one of three sampled residents (Resident 28). There were 3 errors observed during medication administration with 31 opportunities for errors which yielded a 9.68 % error rate. On 2/20/2025, the facility failed to administer the full dose of 3 out of 13 medications for Resident 28 via Resident 28's gastrostomy tube (G-Tube - tube that is placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medications). This deficient practice could potentially result in Resident 28 not getting the full efficacy (the ability to produce a desired or intended result) and benefits of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two medications (Senna and Docusate Sodium [medications used to treat constipation and were labeled properly in one of two sampled medication carts (Med Cart 2) in accordance with the facility's policy and procedure (P&P), titled, Administering Medications. This deficient practice had the potential for residents to be administered ineffective and contaminated medications and the potential to compromise the health, safety, and well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fortified diets were provided for two of two sampled residents (Resident 29 and Resident 112). This deficient practice had the potential for Residents 29 and 112 not to get the caloric intake ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were no expired items, in one of one kitchen's (Kitchen 1) storage. This deficient practice had the potential to cause food-borne illnesses (illness caused by food contaminated with infectious organisms) among the residents consuming food at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices for 20 of 20 sampled residents (Residents 112, 13, 17, 42, 25, 9, 10, 21, 40, 162, 6, 35, 161, 50, 56, 53, 111, 29, 30, and 114) by failing to ensure, a.&b. two of eight sampled residents (Residents 29 and 30) who exhibited signs and symptoms of norovirus (a highly contagious virus that can cause vomiting, diarrhea and dehydration) were asymptomatic (did not have signs and symptoms [S/S]) prior to discontinuing contact (microorganisms spread through the direct and indirect contact) isolation (staying away/kept away from others) precautions. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1) A call light was functional for 1 of 1 sampled resident (Resident 7). 2) 7 out of 7 bathrooms were in good repair. 3) 1 of 1 sampled resident's (Resident 13) bed control was functional. These deficient practices had the potential for Residents 7, 13, and residents in Rooms A-D to be placed at risk for injury, a decline in the resident's health, and a delay in meeting the resident's needs for toileting and assistance. Cross Reference F584 and F919.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and privacy during patient care for one of one sampled resident (Resident 22). This deficient practice had the potential to affect Resident 22's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a proper assessment was conducted for the self-administration (take or do something for yourself that would normally be done by someone else) of Pepto Bismol Ultra (medication used to treat occasional upset stomach, heartburn, and nausea), for one of one sampled resident (Resident 53). On 2/18/2025, there was an almost empty bottle of Pepto Bismol Ultra in Resident 53's room. The facility failed to obtain a consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from Resident 53 and a physician's order for the self-administration of the medication as indicated in the facility's policy and procedures (P&P), titled, Administering Medications and Self-Administration of Medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one of one sampled resident (Resident 32) after receiving positive lab results for clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea). This deficient practice had the potential to negatively affect the provision of care and services for Resident 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure toileting was offered to one of one sampled resident (Resident 14) every two hours as indicated in Resident 14's care plan (CP), titled, At Risk for Falls. This deficient practice had the potential to result in falls and injury to Resident 14.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the licensed nurse followed the physician's order for indwelling catheter care for one of one resident (Resident 22). This deficient practice had the potential to result in Resident 22 experiencing complications with the use of an indwelling catheter and to affect Resident 22's physical wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 28), received appropriate care and services during gastrostomy tube (G-Tube - tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) medication administration. On 2/20/2025, Licensed Vocational Nurse (LVN) 1 used apple sauce to mix Resident 28's medications during administration via Resident 28's G-Tube. This deficient practice had the potential to cause tube-associated complications such as feeding tube occlusions (risk of clogging) to Resident 28's G-Tube.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food served to the residents was served at a temperature that was safe and appetizing. This deficient practice had the potential to result in food that was not appetizing or palatable to the residents consuming the food and result in resident caloric goals not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning call light for one of one sampled resident (Resident 7). This deficient practice had the potential for delay in care and services to meet Resident 7's needs for hydration, toileting, and activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one kitchen (Kitchen 1) area was kept free of pest. On 2/18/2025, two dead cockroaches were found in Kitchen 1. This deficient practice had the potential to result in food-borne illnesses (illness caused by food contaminated with infectious organisms) due to harboring of pest.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement person-centered care-plans for 3 of 3 (Resident 46, Resident 35 and Resident 38) sampled residents when: a. There was no care plan created for Resident 46 who was diagnosed with abdominal distension (swollen belly, enlarged). b-c. For Resident 35 and Resident 38, the facility did not follow an existing care plan's intervention to trim, and clean Resident 35's and Resident 38's nails on bath day and as necessary. These failures had the potential to result in inconsistent implementation of care and had the potential to result in physical declines to Residents 46, 35, and 38 and result in infections to Residents 35 and 38. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary grooming services were provided for three of six sampled Residents (Residents 3, 35, and 38) as indicated in the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care of, by failing to: 1. Ensure Resident 3, who had a left contracted (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) hand, had trimmed and clean fingernails. 2. Ensure Resident 35's fingernails and toenails (hard, smooth covering that protects the upper part of the end of a toe) were kept trimmed and clean. 3. Ensure Resident 38's fingernails were kept trimmed and clean. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistive hearing devices were available for one of one sampled resident (Resident 15) who was hard of hearing (HOH). Resident 15 was not provided with audiology (health care professionals who identify, assess, and manage disorders of hearing, balance, and other neural systems) services to address Resident 15's hearing impairment. This failure had the potential to result in further hearing loss and a psychosocial decline to Resident 35 and the potential to affect Resident 15's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent (%) or greater during medication administration observation. The facility had 25 medication administration opportunities observed and two of the 25 medications administered resulted in a medication error rate of 8%. The errors consisted of: a. For Resident 33, who had a gastrostomy tube (GT- tube inserted through the belly that brings nutrition directly to the stomach) and who could not receive solid textures by mouth, the facility failed to ensure the physician's order indicated administration of Bactrim by GT, the order indicated an incorrect route to administer by mouth to Resident 33. b. For Resident 4, the facility failed to administer Peridex (a medication that treats gum disease) as indicated by pharmacy recommendations to Resident 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS, a standardized assessment and care-screening tool) was accurate for one of one sampled resident (Residents 54). Resident 54's MDS incorrectly indicated Resident 54 was dehydrated (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). This failure had the potential to result with inadequate treatments and/or services to Resident 54.

Inspectors wroteBased on interview and record review, the facility failed to post actual worked nursing hours at the start of each shift in one of one Nursing Stations (Nursing Station 1) as indicated in the facility's Policy and Procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised August 2022. This failure had the potential to result inaccurately reflecting the actual nurses providing direct care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure infection prevention and control practices were included in the facility's, Water Management Program (WMP, a program develop to identify hazardous conditions and taking steps to minimize the growth and transmission of Legionella [bacteria that causes severe lung inflammation called Legionnaires' disease, LD]) and other waterborne pathogens [living thing that causes disease]) by failing to: Develop specific control measures per facility risk area used to control the introduction and/or spread of Legionella. These failures could potentially result in the growth of Legionella and other opportunistic waterborne pathogens and had the potential to result in the development and transmission of LD which could compromise the health and safety of all residents residing at the facility.