Montevista Rehabilitation and Skilled Care

Inspectors wroteBased on record review and interview, the facility failed to: a. verify and obtain clarification from the physician to determine how often to flush the cholecystostomy drain and to measure and record the drain output for 1 (#1) of one sampled resident with a cholecystostomy drain; and b. administer medications as physician ordered for 1 (#1) of 1 sampled resident reviewed for new admissions to the facility. The administrator reported 88 residents resided in the facility and had 47 new admits to the facility in the last 30 days. The administrator reported they currently had no cholecystostomy drains in the facility.

Inspectors wroteBased on record review and interview, the facility failed to implement a baseline care plan to include a IR drain/cholecystostomy drain within 48 hours of admission to the facility for 1 (#1) of 1 sampled resident reviewed for an IR drain. The administrator reported 47 new admissions in the past 30 days.

Inspectors wroteBased on record review and interview, the facility failed to document a a skin assessment for 1 (#1) of 2 sampled residents reviewed for physician ordered wound treatments. The administrator identified 88 residents resided in the facility and the facility matrix showed seven residents had wounds in the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a policy for cholecystostomy drain care for 1 (#1) of 1 sampled resident with a cholecystostomy drain and ensure the nursing staff were properly trained and determined competent for 3 (LPN #3, 5 and #6) of 4 sampled LPNs interviewed for drain care. The administrator reported 88 residents resided in the facility and had no cholecystostomy drains in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's representative was notified of changes in skin condition for 1 (#1) of 3 sampled residents reviewed for notifications. The administrator identified 88 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure care plans were updated with smoking interventions for 2 (#2 and #3) of 3 residents sampled for smoking safety. The administrator reported 14 smokers resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide staff supervision while smoking for 1 (#1) of 3 residents sampled for smoking supervision. The administrator reported 14 smokers resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to investigate an allegation of abuse and determine when to report the allegation for one (#3) of three sampled residents reviewed for abuse. The administrator identified 92 residents resided in the facility. The administrator reported six allegations of abuse in the past ninety days.

Inspectors wroteBased on record review and interview, the facility failed to ensure a registered nurse was on duty for at least eight consecutive hours a day, seven days a week.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff served prepared food with clean tongs and restrained all hair with beard guards as indicated.

Inspectors wroteBased on record review and interview, the facility failed to complete a discharge summary to include a recapitulation of the resident's stay for one (#42) of three residents reviewed for discharge. The DON reported there had been 33 discharges in the previous 30 days.

Inspectors wroteA past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 04/04/24 related to the facility's failure to provide adequate supervision to ensure a resident remained safe and free from elopement. The facility failed to provide adequate supervision and interventions to prevent the resident from exiting the facility and leaving the premises unsupervised. On 05/01/24 at 9:57 a.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to provide adequate supervision to protect the resident and prevent elopement. Based on record review and interview, the facility failed to ensure a resident received adequate supervision to prevent elopement for one (#3) of four sampled residents reviewed for elopement. The Administrator reported a resident census of 80.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received food prepared to meet the resident's needs, which resulted in hospitalization, for one (#1) of four residents reviewed for therapeutic diets. The administrator reported a census of 84 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a medication sent home with a resident was their medication for one (#2) of eight residents whose records were reviewed for medications. The Resident Census and Conditions of Residents, dated 09/12/23, documented 88 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's pain was controlled for one (#95) of two sample residents were reviewed for pain. The facility failed to have a physician ordered pain medication available for the resident when they requested two separate doses at six hour intervals. The resident requested to go to the hospital due to uncontrolled pain. The Resident Census and Conditions of Residents form, dated 07/09/23, documented 91 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure and maintain a sanitary kitchen. The facility failed to ensure: a. food products were properly stored, b. food service equipment was kept clean, and c. sanitary hand hygiene practices were implemented while handling food. The Resident Census and Conditions of Residents report, dated 07/09/23, documented 91 residents resided in the facility and three residents received tube feeding.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure the inside of the facility was kept clean. The Resident Census and Conditions of Residents report, dated 07/13/23, documented a census of 91 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a medication was available to administer as ordered by the physician for one (#95) of two residents whose records were reviewed for pain. The Resident Census and Conditions of Residents, dated 07/09/23, documented 91 residents resided in the facility.