Monte Vista Hills Healthcare Center

Inspectors wroteBased on the facility bowel care standing orders, record review, and staff interview, it was determined the facility failed to follow facility bowel care standing order of delivering specific medications when residents do not have BM within 72 hours for 5 of 14 residents (#6, #11, #20, #24, and #57) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure resident's privacy was maintained during personal cares. This was true for 1 of 1 resident (Resident #39), when staff were providing personal cares in resident rooms. This deficient practice placed residents at risk of embarrassment and diminished sense of self-worth.

Inspectors wroteBased on review of the State Operations Manual, observation, and staff interview, it was determined the facility failed to ensure residents were free from accident hazards for 1 of 1 resident (Resident #55) whose room was observed for environmental safety. This deficient practice had the potential to cause physical harm if portable oxygen cylinders were not properly secured from falling over.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 4 residents (#6 and #20) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on observations, record review, and staff interviews it was determined the facility failed to ensure medications were stored in locked compartment, and medications and biologicals were not expired. This was true for 1 of 2 medication carts reviewed and 1 of 1 resident (Resident #55) room observed for medication storage. This failure created the potential for undetected misuse of medication, residents to receive expired medications with decreased efficacy, and use of expired biologicals.

Inspectors wroteBased on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation, interview, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified director of food and nutrition services. This deficient practice had the potential to affect 61 of 62 residents who received meals prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, policy review, and review of the Idaho and FDA Food Codes, the facility failed to appropriately store, distribute, and label foods; clean ovens; and perform appropriate hand hygiene. This deficient practice had the potential to affect 61 of 62 residents who received meals prepared in the facility's kitchen.

Inspectors wrote4. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including metabolic encephalopathy, sepsis, and pneumonia. Resident #33's record documented she was transported and admitted to the hospital on [DATE], with a diagnosis of pneumonia and again on 5/25/24, with a diagnoses of acute chronic respiratory failure and sepsis secondary to pneumonia. Resident #33's record did not include documentation of the information that was provided to the hospital upon Resident #33's transfer. On 7/26/24 at 11:58 AM, the SSD, who is responsible for transfer and discharge documentation and notification, stated he was not aware of what documentation was needed for a hospital transfer. Based on policy review, record review, and staff interview, it was determined the facility failed to ensure continuity of care by not providing pertinent health information to the receiving hospital. [...]

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to secure and label unidentified loose pills in 1 of 1 medication cart (North side medication cart), audited for labeling and storage of medication. This failure created the potential for residents to miss doses of medication.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an advanced directive. This was true for 1 of 16 residents (Resident #25) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice and comprehensive care plans were followed for 2 of 16 residents (Residents #17 and #41) reviewed for quality of care. Resident #17 was at risk of wound infection when her wound care was not performed as directed by her care plan. Resident #41 was at risk for adverse outcomes when his urinary catheter tubing was not secured as directed by his care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure positioning devices were in place to prevent further contractures for 1 of 1 resident (Resident #6) reviewed for range of motion. This deficient practice could result in further contractures and pain for Resident #6.

Inspectors wroteBased on interview, record review, and policy review, it was determined the facility failed to ensure staff used a gait belt per the policy during a transfer that resulted in a potential for more than minimal harm for 1 of 5 residents (Resident #116) reviewed for accidents.

Inspectors wroteThe facility's Oxygen Use policy with a revision/review dated January 2024, documented the filter on the concentrator should be checked at least every month and cleaned as needed. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy, chronic respiratory failure, and diabetes. Resident #14's physician order documented to change tubing, clean filter, and change oxygen water bottle every Sunday on the night shift, starting 12/19/21. On 7/22/24 at 11:22 AM, surveyor observed the filter on Resident #14's oxygen concentrator to have a thick layer of dust. On 7/26/24 at 8:48 AM, the IP stated the night shift nurse is responsible for cleaning the filters on the side of the oxygen concentrators. Additionally, the IP stated the oxygen concentrators should be cleaned monthly and PRN. [...]