The Springs of Mt Vista

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the laboratory waiver was renewed for 1 of 1 facility requiring a waiver to perform testing. Specifically, the facility Centers for Medical & Medicaid Services Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver (COW) was expired.

Inspectors wroteBased on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to maintain Legionella surveillance for 1 of 1 water management plan and maintain sanitary conditions for 1 of 1 resident unit refrigerator reviewed for infection control.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide a diet based on nutritional needs of 6 (Resident #4, #5, #8, #14, #27, and #47) of 37 residents reviewed for nutritional dietary needs and weight loss. Specifically, Residents #4, #5, #8, #14, #27, and #47 did not receive an enhanced/fortified diet as ordered.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure physician ordered foods were provided for 3 (Residents #4, #14, and #27) of 37 residents reviewed for dietary orders. Specifically, Resident #4 did not receive two house shakes, Resident #14 did not receive ice cream at lunch, and Resident #27 did not receive double portions of biscuits and gravy at breakfast, as ordered by a physician.

Inspectors wroteBased on observation, and interview, the facility failed to ensure staff properly washed hands with soap and water to prevent cross-contamination, and equipment was in good repair.

Inspectors wroteBased on observations, interviews, record review, it was determined the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed for 1 (Resident #72) of 27 sampled residents who were reviewed for MDS assessment accuracy. Specifically, the facility failed to ensure information regarding a resident's diagnosis reflected the resident's current condition.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to ensure an accurate care plan for 1 (Resident #50) of 27 sampled residents who were reviewed for a comprehensive care plan.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined the facility failed to include a cognitively impaired resident's representative in the care plan meetings for 1 (Resident #5) of 28 residents reviewed for development of comprehensive care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food stored in the facility's refrigerator, freezer, and dry storage were dated when received and/or opened, spices were discarded after a year, foods stored in opened boxes were in sealed bags, and perishable foods were accurately dated with the date prepared in 1 of 1 kitchen. The failed practice had the potential to affect 71 residents who received meals from the kitchen as documented on the Dietary Diet report provided by the Director of Nursing (DON) on 07/19/23 at 3:44 PM.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were refunded promptly to the resident or resident's representative within 30 days after the resident's discharged and/or death for 9 (Residents #66, #67, #68, #69, #70, #71, #72, #73 and #115) of 9 sampled residents who had been discharged /expired and had a remaining balance in the resident trust fund account. This failed practice had the potential to affect 51 residents who had a personal trust account managed by the facility, according to the Trial Balance Report dated [DATE], provided by the Administrator on [DATE] at 1:24 PM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure No Smoking/Oxygen in Use signs were posted outside of the resident room for 3 (Resident #54, #62 and #167) sampled residents and the oxygen flow rate was administered per Physician Orders for 1 (Resident #54) sampled resident of 12 (Residents #17, #21, #33, #52, #54, #57, #58, #62, #116, #117, #120 and #167) who required oxygen therapy, and failed to ensure Bilevel Positive Airway Pressure (BiPap) masks and tubing were properly stored for 1 (Resident #167) of 1 sampled resident who required a BiPAP.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for 2 (Residents #117 and #167) of 2 sampled residents whose Care Plans were reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure necessary care and treatment were provided for management of a Peripherally Inserted Central Catheter (PICC) for 1 (Resident #57) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure tobacco products and ignition devices were secured for 1 (Resident #34) of 4 (Residents #17, #34, #48 and #117) sampled resident identified as a smoker in the facility per a list provided by the Administrator on 07/17/23 at 11:10 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a secure manner. This failed practice had the potential to affect 4 residents who are independent in ambulation as stated on the Resident Census and Conditions of Residents, form CMS-672.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified Social Worker on a full-time basis as required by a facility licensed to provide care for more than 120 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff documented dryer lint trap cleaning accurately to prevent the potential for fire in 1 of 1 facility.