Vista Manor Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. Occupational therapist A (OT A) did not perform hand hygiene (HH - to clean the hands, including washing with soap and water or using an alcohol-based hand rub [like hand sanitizer]) after removal of gloves and before donning (putting on) of a new pair of gloves and did not change gloves after assisting Resident 2 with toileting; and2. Certified nursing assistant B (CNA B) did not perform hand hygiene after touching Resident 3's environment. These failures had the potential to compromise resident's health and safety, and spread infections to residents, staff, and visitors. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store food and maintain the kitchen under sanitary conditions when: 1. Several food items were undated for use by dates in the refrigerators, freezers, and dry goods area, 2. Ice buildup was noted on the Dessert Freezer #2, 3. A black electric fan had dust accumulated on its surface, 4. Black residue was on the caulking of the dishwasher round sink and 3-compartment sink. Failure to follow facility procedures and standards of practice for food safety has the potential of exposing residents, who are served food from the kitchen, to foodborne illnesses.

Inspectors wrote2. Review of Resident 64's clinical record indicated he was admitted on [DATE] with diagnoses including Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (muscle weakness of partial paralysis on one side of the body that can affect arms, legs, and facial muscles) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, Dysphagia (difficulty in swallowing) following cerebral infarction and Encounter for attention for Gastrostomy (surgical procedure used to insert a tube, often referred as G-Tube, through the abdomen and into the stomach). [...]

Inspectors wroteDuring observation, interview and record review, the facility failed to maintain equipment for one of 19 sampled residents (Resident 10) when Resident 10's bedside rolling table edge trimmings were peeled off and the footboard of her bed was wobbly (shaky). These failures posed as hazardous risks for injury to Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a safe and effective manner when expired medications were found in two of two medication rooms. This failure could result to unsafe medication administration to residents.

Inspectors wroteBased on observation, interview, and record review, the facility had a 17.6% medication error rate when five medication errors out of 28 opportunities were observed during medication administration for four residents (Resident 2,50,63, and 122). This failure had the potential to compromise the resident's medical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and labeled in accordance with professional standards for food safety when: 1. Two refrigerators did not have internal thermometers and; 2. A bag of food inside of the resident's refrigerator did not have a label, These failures had the potential to cause the growth of microorganisms and foodborne illness for the 64 residents eating at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Staff did not wear N95 masks (a high filtering facepiece device designed to achieve a very close facial fit that filter at least 95% of airborne particles) properly; 2. Certified nursing assistant I (CNA I) did not disinfect the vital signs machine (blood pressure machine, pulse oximeter, thermometer in one machine attached to a pole with tray and wheels) after use; 3. Resident 35's oxygen tubing was not dated and labeled; 4. Licensed nurses did not label and date the oxygen tubing for Residents 12 and 24; 5. Staff did not perform hand hygiene during medication pass; 6. Staff did not disinfect the insulin vial rubber top; 7. Resident 7' oxygen tubing was not dated and labeled and nebulizer (breathing treatment machine) mask was not stored properly; 8. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 328) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying then that Part A coverage is being terminated and providing information on how to file an appeal of that decision) letter in a timely manner. This failure had the potential to prevent the resident from filing a timely appeal of the decision to discharge from Medicare Part A services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three employees was screened in accordance with their policies when there was no documentation that a background check was conducted prior to hire. This failure had the potential to compromise the safety and security of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop care plans for four of 18 sampled residents (Residents 18, 24, 175 and 14). 1. For Resident 18, the facility did not develop a care plan to address the use of insulin; 2. For Resident 24, the facility did not develop a care plan to address the use of oxygen; 3. For Resident 175, the facility did not develop care plans to address the use of oxygen and antidepressant medication; and 4. For Resident 14, the facility did not develop a care plan to address the use of anticoagulant (blood thinner). This failure had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to appropriate professional standard of care for one of two sampled residents (Resident 58) when a licensed nurse forcefully introduces through a gastric-tube (g-tube inserted through the belly) the medication causing leakage. This failure had the potential for residents not to received complete dose of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order to apply compression stockings (elastic stockings apply to the legs) to one of 18 sampled residents (Resident 21) related to edema (swelling) of both lower extremity. This failure had the potential to affect the residents physical and mental well being in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 18 sampled residents (Residents 175 and 69) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings or behavior) when: 1. For Resident 175, licensed nurses did not monitor for side effects and target behaviors (behaviors intended to be changed or eliminated by the psychotropic medication); and 2. For Resident 69, licensed nurses did not consistently monitor for side effects and target behaviors, and did not complete an abnormal involuntary movement scale assessment (AIMS assessment, a tool used to monitor for abnormal bodily movements caused by antipsychotic medication). These failures had the potential to compromise the residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for staff and residents when staff used paper towels to light the pilot light in the oven. These failures had the potential to cause staff injuries and a fire hazard for 66 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility had a 42.86% medication error rate with 12 medication errors during 28 opportunities were observed during the medication passes (med pass, licensed nurses administer medication to residents) for seven of 10 observed residents (Residents 4, 13, 16, 24, 34, 65 and 196). Seven of nine observed licensed nurses made medication errors during the med pass. These failures had the potential to jeopardize residents' medical condition and health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary condition when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. The interior of the ice machine door and ice bin (the bin inside the ice machine where the ice is collected) had multi-color substance; The portable ice container had brown substance inside the container wall; 3. The can opener had multi-color substances; 4. Food items past use by date stored in Freezer 1; 5. There was no air gap ( no space in-between drain spout and the in-floor drain inlet) for the coffee machine and ice machine drain system; 6. Open bags of food items were not sealed or closed in Freezer 2; 7. Expired food items stored in Refrigerator 1; 8. Ready-to-eat Jello stored next to the fruits in Refrigerator 2; 9. Dishwasher sanitizer test strips was expired; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staff follow proper infection control practices during medication passes (med pass: nurse administered the medications to residents per physician's order) for seven of 10 observed residents (Residents 4, 13, 16, 24, 65, 196 and 346 ) and one resident with catheter out of 18 sampled residents (18). These failures had the potential to result in cross-contamination and the spread of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to provide privacy and dignity for two of 10 residents (Residents 346 and 65) during medication administration. This failure had potential to exposed residents to the public view and lower residents' self-esteem.

Inspectors wroteBased on interview, and record review, the facility failed to ensure interventions to prevent further fall incidents for two out of 18 sampled residents (64 and 73) when: 1. For Resident 64, fall interventions were not implemented to prevent falls. 2. For Resident 73, fall interventions were not reevaluated for effectiveness and implementation. This failure had resulted in repeated falls which could cause further decline in the resident's physical function.

Inspectors wroteBased on interview and record review, the facility failed to ensure the controlled substance medications (medication with a high potential for abuse and addiction) was disposed properly for Resident 56. This failure had the potential to result in residents not getting medications per physician's order and potential to cause controlled medication misuse and abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications in a safe and sanitary condition when: 1. Medication Cart 1 (MC 1) had multi-color substances and sticky substance; expired medication stored in MC 1. 2. MC 2 had multi-color substances and sticky substances; pill crusher (device to crush tablet medication into powder) had multi-color substances. Eye drop medication stored with oral medication. Expired medication stored in MC2. 3. MC 3 had multi-color substance; pill crusher had multi-color substances. Expired eye drop medication stored in MC 3. Eye drops stored with oral and cream medication. Insulin (medication to lower high blood sugar level) injection pens had no open or expiration date. 4. MC 4 had multi-color substance and sticky substances. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service when: 1. Dietary staff did not know how to check thermometer accuracy correctly during the calibration process; 2. Dietary staff did not know how to correctly check the dishwasher's sanitizer and quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and used to manually sanitize dishes). The lack of knowledge regarding food and nutrition services had the potential for dietary staff not being able to carry out their job functions properly and ensure sanitary conditions in the kitchen.