Mountain Vista Health Center

Inspectors wroteBased on observations and interviews, the facility failed to remove medications and biologicals that were stored and labeled properly according to professional standards in three of five medication carts and two of four medication storage rooms. Specifically, the facility failed to:-Ensure expired medications were discarded; and,-Ensure a drug buster was not stored next to medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure 16 residents on a mechanical soft diet received food and fluids prepared in a form designed to meet his or her needs per speech therapy recommendation, physician orders and the residents care plan. Specifically, the facility failed to ensure residents who were prescribed a mechanical soft diet had food prepared according to their diet orders of mechanical soft as indicated on their meal tray cards.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#71 and #86) of four residents out of 51 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to effectively resolve Resident #71 and Resident #86's written grievances (complaints) about call lights previously.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for two of four units. Specifically, the facility failed to:-Ensure staff donned (put on) personal protective equipment (PPE) when providing care for a resident who was on enhanced barrier precautions (EBP);-Ensure housekeeping staff followed proper cleaning procedures for disinfecting resident rooms and high frequency touched areas; and,-Ensure staff wore personal protective equipment (PPE) when providing care for Resident #56 who was on transmission based precautions (TBP), which included contact and droplet precautions.

Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, the facility failed to ensure two CNAs (#2 and #3) of five CNAs received 12 hours of annual training.

Inspectors wroteBased on record review and interviews, the facility failed to investigate and document incidents of physical abuse involving two (#2 and #3) of three residents reviewed out of eight sample residents. Specifically, the facility failed to conduct a thorough investigation of physical abuse involving Resident #3 and Resident #2.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to properly prepare and store food and to maintain sanitary conditions in the main kitchen. Specifically, the facility failed to: -Ensure the main kitchen was clean and sanitary; -Ensure damaged cans were disposed of; and, -Ensure food was labeled and dated.

Inspectors wroteBased on record review and interviews, the facility failed to ensure facility resources were administered in a manner that allowed its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. Specifically, the facility failed to: -Provide sufficient leadership to address and or avoid multiple concerns; -Prevent, report and fully investigate allegations of abuse timely to provide immediate protections to residents at risk of being victimized and re-victimized; -Report an injury of unknown origin in a timely manner so that an accurate timeline of events could be established and the injury could be effectively treated and monitored; [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to promote dignity and respect for one (#12) of three residents out of 14 total sample residents. Specifically, the facility failed to promote dignity and respect by sitting with the Resident #12 at the dining table and providing meal assistance in a dignified manner.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse, neglect, exploitation or mistreatment and injuries of unknown origin to the state oversight agency in accordance with state laws for two of five alleged abuse violations. Specifically, the facility failed to: -Timely report an allegation of sexual abuse by Resident #6 towards Resident #4, Resident #5, Resident #2 and Resident #3 to the State Agency; and, -Report Resident #7's injury of unknown origin to the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of two residents out of five sample residents received treatment and care for optimal skin condition of a pressure wound and injury of unknown origin, in accordance with professional standards of practice. Specifically, the facility failed to: -Develop a care plan for treating Resident #1's moisture-associated skin damage (MASD) and preventing pressure injury due to immobility; -Reassess alternative methods of providing Resident #1's pressure-relieving interventions when the resident refused offers to be repositioned; and, -Reassess treatment methods and implement alternative interventions when Resident #1 developed a skin tear and his MASD worsened.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychosocial well-being for two (#7 and #14) of three residents reviewed for dementia care out of 14 sample residents. Specifically, the facility failed to develop and implement effective dementia management-focused interventions to prevent Resident #7 and Resident #14 from wandering into other residents' rooms.

Inspectors wroteBased on record review and interviews, the facility failed to investigate an allegation of physical abuse for two (#10 and #11) of six residents reviewed out of 11 sample residents. Specifically, the facility failed to thoroughly investigate alleged abuse between Resident #10 and Resident #11.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents out of 10 sample residents was free from neglect. Resident #1 suffered an injury of unknown origin to the left forehead, a hematoma (a localized swelling of pooled blood due to injury or trauma), on [DATE] following a shower provided by hospice certified nurse aide (CNA) #1. The resident's son was notified of the forehead hematoma at 3:06 p.m., but the staff did not conduct a full skin assessment on the resident afterward to determine if other injuries were present. Resident #1 sustained a fall three days later, on [DATE]. No injuries were reported. -However, the staff did not conduct a full skin assessment to determine if other injuries were present. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to two (#87 and #92) of three residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 34 sample residents. Resident #87 was admitted on [DATE]. Her admission weight was 113.8 pounds (lbs). The resident maintained a weight between 113 lbs and 118 lbs between January 2023 and January 2024. The resident lost 12.3 pounds between 1/4/24 and 2/15/24. The facility did not weigh the resident monthly despite a physician's order for monthly weights. The registered dietitian (RD) recommended weekly weights and weights were not consistently obtained on a weekly basis. The resident had poor meal intake and refused meals. There were no preventative measures implemented to address her eating patterns to ensure her intake was adequate. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure standards of practice were followed for a respiratory syncytial virus (RSV) outbreak in the secured unit were followed; -Ensure Resident #17, #31, #7, #36 and #11 received the RSV vaccination upon consenting for it; and, -Ensure the facility had a water monitoring program to prevent the potential spread of Legionella and other waterborne pathogen infections.

Inspectors wroteBased on record review and interviews, the facility failed to establish an infection control program for antibiotic stewardship to include an antibiotic stewardship program. Specifically, the facility failed to have a process in place to track antibiotic usage in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure all grievances were followed up on and resolved timely and appropriately. Specifically, the facility failed to make prompt efforts to resolve resident and resident representative grievances about a variety or concerns including: -Provision of timely care; -Responding to resident call lights; -Ensuring competent staff; -Ensuring agency staff performed care services as assigned; -Ensure a resolution to the resident's complaint about poor care and services; and, -Maintain evidence of the result of all grievances.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure licensed nurses and certified nurse aides (CNA) were evaluated for competency and skill sets necessary to care for residents' needs as identified through residents' assessments and care plans. Specifically, the facility failed to have completed competency and skill sets training with licensed practical nurse (LPN) #3 and CNA#4, #5, #6, #7 and #8. Cross-reference to: -F585 failure to resolve resident grievance about agency nursing staff's competency while providing care assistance; -F692 failure to ensure residents received care and services to meet their nutritional needs; -F700 failure to assess and monitor the use of bed rails; and, -F880 failure to implement and practice proper infection control practices during a respiratory syncytial virus (RSV) outbreak.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#17, #31, #7, #36 and #11) of seven residents reviewed for immunizations out of 34 sample residents. Specifically, the facility failed to: -Administer the pneumococcal vaccination after consent was provided for Resident #17, #31, #7 and #11; and, -Document risk versus benefit education for the pneumococcal vaccination for Resident #36.

Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for four of five CNAs (#4, #5, #6 and #7) reviewed for annual training requirements. Specifically, the facility failed to ensure CNAs #4, #5, #6 and #7 received 12 hours of annual training in all required training topics areas including dementia management training and resident abuse prevention training.

Inspectors wroteBased on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for two (#31 and #47) of five residents reviewed for unnecessary medication of out 34 sample residents. Specifically, the facility failed to ensure consents that reviewed the risk associated were obtained for the usage of psychotropic medications for Residents #31 and #47.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure resident choices for two (#25 and #17) of three residents reviewed for activities of daily living out of 34 sample residents. Specifically, the facility failed to: -Ensure Resident #25 and Resident #17 received showers consistently according to their choice of frequency; and, -Ensure Resident #25's preferences were included in her plan of care.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure two (#17 and #72) out of two residents out of 34 sample residents were free from involuntary seclusion. Specifically, the facility failed to ensure Residents #17 and #72 who resided in the secured unit, had the required assessment to justify such restrictions.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#72) out of 34 sample residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to ensure preventative measures were put in place for Resident #72's hand contracture.

Inspectors wroteBased on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standard of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#25 and #7) of three residents reviewed for pain out of 34 sample residents. Specifically, the facility failed to: -Offer non-pharmacological pain interventions For Resident #25 and Resident #7; and, -Determine an acceptable pain level for Resident #25 and Resident #7.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the correct installation, use and maintenance of transfer bar, (fixed bed rail assistive device) for three of three residents (#37 and #42) using bed canes or transfer bars (type of bed rail) for positioning out of 34 sample residents. Specifically, the facility did not ensure resident safety risk when the use of transfer bar/rails were in use, for Residents #37 and #42 by failing to: -Attempt to use appropriate alternatives prior to installing bed rails/transfer bars/rails; -Assess each resident for risk of entrapment from bed rails prior to installation; -Assess and review the risks and benefits of the bed transfer bar assistive device with the resident and or the resident's representative; [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain emergency response carts equipment in safe operating condition for one out of three emergency carts. Specifically, the facility failed to ensure the emergency response carts were cleaned, maintained and ready for use.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#1) of three residents out of three sample residents reviewed for accident hazards. The facility failed to ensure measures were in place to prevent Resident #1's fall with injuries. Resident #1 was identified as a high fall risk on her 8/6/23 Fall Risk Assessment and the 8/9/23 minimum data set (MDS) assessment documented Resident #1 required extensive assistance of two persons for bed mobility, transfers, toileting and bathing. Resident #1's care plan prior to her fall did not have interventions that included assistance from two people for bed mobility, transfer, toileting and bathing. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for six (#1, #2, #3, #4, #5 and #6) of eight residents reviewed for immunizations out of eight sample residents. Specifically, the facility failed to: -Offer Resident #4 and #6 the pneumococcal vaccine upon admission; and, -Offer additional doses of the pneumococcal vaccine to Resident #1, #2, #3 and #5.

Inspectors wroteBased on record review, interviews, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 (Resident #27) of 19 residents reviewed for MDS accuracy. Specifically, the facility failed to indicate on the MDS that the resident was receiving hospice services.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy, the facility failed to ensure that oxygen was administered in a manner consistent with professional standards of practice for 1 (Resident #42) of 2 residents observed for oxygen administration. Observations revealed Resident #42's oxygen tubing was not bagged/covered to prevent cross contamination when not in use.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to provide pharmaceutical services that assure the accurate acquiring of drugs for 2 (Resident #73 and Resident #74) of 2 residents observed during the 8:00 AM medication pass on 12/07/2022.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of the 8:00 AM medication pass on 12/07/2022 for Resident #73 and Resident #74 revealed there were 29 opportunities for error with two medication omissions, resulting in a 6.9% medication error rate.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to ensure antibiotics were given in accordance to the antibiotic stewardship program for 1 (Resident #73) of 5 residents reviewed for unnecessary medications when staff administered ciprofloxacin 500 milligrams (mg) (an antibiotic) twice a day without laboratory confirmation of a diagnosis of a urinary tract infection (UTI).