Vista Care Center of Milan

Inspectors wroteBased on review of facility self-reported incidents, review of a medication incident investigation, review of staff statements, interviews with staff, and review of facility policy, the facility failed to report allegations of abuse and neglect. This had the potential to affect 38 residents (#2, #5, #8, #10, #11, #13, #14, #16, #18, #19, #22, #26, #30, #37, #38, #40, #44, #46, #49, #52, #53, #55, #56, #88, #57, #59, #61, #63, #66, #67, #70, #72, #77, #78, #79, #80, #82, and #85) residing on unit one. The facility census was 87. Review of a statement dated 05/21/25 by Licensed Practical Nurse (LPN) #160 revealed she had worked a 12-hour day shift then gave report to the 12-hour night shift nurse LPN #174. LPN #160 revealed she had not left until around 8:00 P.M. [...]

Inspectors wroteBased on medical record review, review of a medication incident investigation, review of staff statements, interviews with staff and residents, and review of facility policy, the facility failed to investigate allegations of abuse and neglect alleged on 05/21/25 and failed to thoroughly investigate an allegation of abuse alleged on 06/04/25. This had the potential to affect 38 residents (#2, #5, #8, #10, #11, #13, #14, #16, #18, #19, #22, #26, #30, #37, #38, #40, #44, #46, #49, #52, #53, #55, #56, #88, #57, #59, #61, #63, #66, #67, #70, #72, #77, #78, #79, #80, #82, and #85) residing on unit one. The facility census was 87. Review of the medical record for Resident #56 revealed an admission date of 07/09/20. Diagnoses included type two diabetes mellitus, bipolar disorder, paranoid schizophrenia, anxiety, hypertension, and chronic obstructive pulmonary disease. [...]

Inspectors wroteBased on review of the medical record, review of a fall investigation, review of staffing assignment records, interviews with staff and residents, and policy review, the facility failed to ensure a resident was reevaluated for transfer assistance after a change in condition and ensure a safe resident transfer. Additionally, the facility failed to ensure falls were immediately reported, immediate post-fall assessments were completed and ensure the completion of a thorough fall investigation. This affected one (#7) of three residents reviewed for falls and had the potential to affect 56 residents residing on unit one and unit two. The facility census was 87. Review of the medical record for Resident #7 revealed an admission date of 02/21/23. [...]

Inspectors wroteBased on medical record review, review of a facility medication incident investigation, review of staff statements, staff and resident interviews, and policy review, the facility failed to ensure medications were administered per physician orders. Additionally, the facility failed to assess and monitor for potential medication interactions and adverse medication effects. This affected two (#55, #56) of three residents reviewed for medications and had the potential to affect 38 residents (#2, #5, #8, #10, #11, #13, #14, #16, #18, #19, #22, #26, #30, #37, #38, #40, #44, #46, #49, #52, #53, #55, #56, #88, #57, #59, #61, #63, #66, #67, #70, #72, #77, #78, #79, #80, #82, and #85) residing on unit one. The facility census was 87. Review of the medical record for Resident #56 revealed an admission date of 07/09/20. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure staff implemented the facility abuse policy by reporting a potential incident of physical abuse, this affected one, Resident #22, of seven residents reviewed for abuse. The facility census was 84. Findings Include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, morbid obesity, Bipolar disorder, anxiety disorder, cognitive communication deficit, schizoaffective disorder and psychosis due to unknown physiological condition. Review of the most recent quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was severely cognitively impaired and required extensive assistance to dependence of two persons for completing her activities of daily living (ADLs). [...]

Inspectors wroteBased on medical record review, resident interview, staff interview and facility policy review, the facility failed to ensure physician orders were accurately transcribed and residents received the correct medications. This affected two (#61 and #29) of seven residents reviewed for medication administration. The facility census was 84. Findings Include: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, dementia with behavioral disturbance and psychotic episodes, mood disturbance, anxiety disturbance, and Bipolar disorder. Review of the most recent significant change minimum data set (MDS) 3.0 assessment dated [DATE], revealed the resident had severe cognitive impairment, delusions, and hallucinations. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of the facility investigation, review of law enforcement reports, review of fire department reports, review of body camera footage, law enforcement interviews, and review of policy for the secure unit, the facility failed to provide adequate supervision to ensure a resident at risk for elopement and residing on a secured unit did not elope from the facility. [...]

Inspectors wroteBased on medical record review, staff interview, resident interview, review of Controlled Drug Receipt/Record/Disposition Form, and policy review, the facility failed to ensure medications to relieve pain were obtained in a timely manner for administration. This resulted in Actual Harm to Resident #05 when her physician-ordered supply of a narcotic analgesic, Oxycodone, was exhausted on 09/14/24 at 4:00 A.M. and the facility did not timely obtain a new written prescription from the ordering provider. This delay in obtaining a new prescription led to Resident #05 not receiving the medication for 91 hours which led to the resident experiencing chronic pain horrible, rated her pain at a 10/10, indicating the worst possible pain, and ultimately requiring an emergency department visit on the afternoon of 09/17/24 to obtain a dose of Oxycodone and a short-term written prescription. [...]

Inspectors wroteBased on observation, resident and staff interview, review of the menu and review of the dietary spreadsheet, the facility failed to ensure food was served per the facility menu and spreadsheet. This had the potential to affect all 86 residents residing in the facility who received food from the facility. The facility census was 86.

Inspectors wroteBased on observation, and staff interview, the facility failed to ensure safe and sanitary storage of food items in the kitchen. This affected all 86 residents residing in the facility. The facility census was 86.

Inspectors wroteBased on observation, staff and resident interview, medical record review, review of facility policy, review of infection control logs and review of glucometer manufacturer instructions, the facility failed to ensure residents with communicable diseases were appropriately isolated and failed to ensure proper personal protective equipment (PPE) was utilized for residents in transmission-based precautions (TBP). This affected two residents (#09 and #14) of two residents reviewed for TBP. Additionally, the facility failed to ensure proper disinfection of shared glucometers. This affected one resident (#04) of one resident reviewed for glucometer use. The facility identified 24 residents with glucometer checks. [...]

Inspectors wroteBased on observation, staff and resident interview, record review, and policy review, the facility failed to ensure residents were treated in a respectful and dignified manner by staff. This affected two (#26 and #27) and had the potential to affect ten other unnamed residents who were in attendance at a smoke break. Additionally, the facility also failed to ensure indwelling urinary catheter drainage bags were covered in a dignified manner. This affected two (#68, and #41) of two residents observed for catheter care. The faciliy census was 58.

Inspectors wroteBased on observation, staff interviews and resident interviews, the facility failed to ensure the facility was clean and in good repair. This affected all 32 residents (on unit-3 secured unit), (#1, #2, #6, #7, #10, #12, #15, #18, #22, #23, #24, #26, #27, #34, #36, #37, #39, #40, #46, #47, #48, #53, #55, #57, #63, #66, #69, #76, #79, #85, #189 and #190) that reside on the secure unit. The facility census is 86.

Inspectors wroteBased on staff interview, record review, review of infection control logs, and policy review, the facility failed to notify the residents' representative and physician of positive COVID-19 test results. This affected three (#23, #76, and #53) of 24 resident reviewed for infection control practices. The facility census was 86.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure residents met the criteria to be admitted to and reside on the secure unit. This affected one (#5) of three residents reviewed for involuntary seclusion. The facility census is 86.

Inspectors wroteBased on medical record review, staff interview, review of the Certification and Licensure System (CALS) and review of facility policy, the facility failed to report a resident elopement to the state agency. This affected one resident (#69) of three residents reviewed for elopement risk. The facility census was 86.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to timely develop a comprehensive care plan based on resident needs and implement care planned interventions. This affected two (#72 and #46) of 21 residents reviewed for care planning. The facility census was 86.

Inspectors wroteBased on record review, staff interview and policy review the facility failed to ensure medications were given as ordered. This affected one (#291) of three residents reviewed for medication administration. The census was 86.

Inspectors wroteBased on staff interview, record review, and policy review, the facility failed to ensure timely laboratory testing to monitor therapeutic drug levels for psychotropic medications was completed as ordered. This affected one (#29) of three residents reviewed for mood and behavior. The facility census was 86.

Inspectors wroteBased on observation, staff interview and review of facility meal tickets, the facility failed to ensure resident's food preferences were followed for Resident #29 and Resident #62. Additionally, the facility failed to ensure meal tickets accurately reflected resident preferences for Resident #80. Lastly, the facility failed to offer Resident #80 an alternative for the breakfast meal. This affected three (#29, #62, and #80) of four residents reviewed for food preferences. The facility census was 86.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to provide a resident with physician-ordered adaptive equipment for meals. This affected one (#05) of four residents reviewed for nutrition. The facility identified 14 residents who required adaptive equipment at meals. The facility census was 86.

Inspectors wroteBased on staff interview, record review, review of infection control logs and review of facility policy, the facility failed to ensure complete and accurate medical records. This affected three (#23, #76, and #53) of 24 resident reviewed for accurate medical records. The facility census was 86.

Inspectors wroteBased on medical record review, witness statement review, review of a facility investigation, and staff interview, the facility failed to notify the physician and the responsible party timely of a resident fall. This affected one (#7) of three residents reviewed for falls. The facility census was 84.

Inspectors wroteBased on medical record review, witness statement review, review of a facility investigation, staff interview, and review of a facility policy, the facility failed ensure appropriate care was provided following a resident fall. This affected one (#7) of three residents reviewed for falls. The facility census was 84.

Inspectors wroteBased on medical record review, review of electronic mail (email) communications, resident and staff interviews and policy review, the facility failed to ensure a resident was free from misappropriation. This affected one (#13) of six residents reviewed for personal funds. The facility census was 82.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure a resident was free from unnecessary medications when the resident received an antibiotic without an adequate indication for use. This affected one (#31) out of six residents reviewed for unnecessary medications. Facility census was 82.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident was free from unnecessary psychotropic medications when as needed (PRN) medication orders for psychotropic drugs were not limited to 14 days. This affected one (#52) of six residents reviewed for unnecessary medications. The facility census was 82. Findings Include: Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, bipolar, heart disease, anxiety, restlessness and agitation. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/13/22, revealed the resident had intact cognition. The resident required supervision for bed mobility, transfers, ambulation. Resident #52 was noted to have verbal behaviors, other behaviors, and rejection of care four to six days during the look back period. [...]

Inspectors wroteBased on medical record review, observation, resident and staff interviews and policy review, the facility failed to ensure an accurate and complete medical record was maintained related to urinary catheters usage. This affected one (#20) of three residents reviewed for accuracy of documentation. The facility census was 82.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the State Tested Nursing Assistants (STNA's) annual performance evaluations were completed as required. This affected two (#268 and #201) of six STNA personnel files reviewed and had the potential to affect all 82 residents residing in the facility. Facility census was 82.

Inspectors wroteBased on observation, staff interview, review of the facility Legionella Environmental Assessment Form, review of Center for Disease Control (CDC) guidelines, and facility policy review, the facility failed handle linens in a sanitary manner, failed to complete water testing for Legionella Disease per facility policy, and failed to complete diagram which identified location of water entering the facility and of water heaters. This had the potential to affect all residents. The facility census was 79. Findings Included: 1. Observation 09/25/19 at 3:10 P.M. of the basement laundry room revealed an isolation cart on the floor sitting in standing water. A storage cabinet filled with clean sheets and bath blankets used for residents was sitting next to a dirty linen bin. Five clean mechanical lift pads were observed hanging over a storage cabinet and touching the floor. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the facility was maintained in a functional and sanitary manner. This affected two rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) which had loose and missing wall tiles and the basement which contained standing water. This had the potential to affect all 79 residents of the facility as well as the employees.