Monte Vista Healthcare Center

In the surveyor’s words

From the most serious findings on record at Monte Vista Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF678Feb 13, 2022

  Based on interview and record review, the facility failed to ensure staff provided Basic Life Support (BLS, activation of the emergency response system, early cardiopulmonary resuscitation [CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased]) for one of two sampled residents (Resident 1) who required such emergency care, by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 performed CPR to Resident 1 who was full code (a patient who chooses to be resuscitated if he or she stops breathing of if the heart stops beating or wishes to have full treatment in life-threatening situations to do CPR) when Resident 1 was suddenly found to be unresponsive, not breathing, and did not have a heart rate. 2. […]

• Immediate jeopardy, patternF880Nov 12, 2021

  Based on observation, interview and record review the facility failed to implement interventions to prevent and control the spread of respiratory diseases such as Coronavirus 19 (COVID-19, a severe respiratory illness caused by virus and spread from person to person) and Influenza virus (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) for 13 of 13 sampled residents (Resident 5, 7, 15, 18, 20, 24, 29, 36, 46, 47, 54, 56 and 209) by failing to: a. […]

• Actual harm, isolatedF744Jan 26, 2023

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), received care and services to prevent a fall by failing to: Assess and monitor Resident 1 for causes leading to episodes of restlessness (the inability to rest or relax) and constantly trying to climb out of Resident 1's bed. As a result, on 1/20/2022, at 4:35 am, Resident 1 climbed out of her bed unnoticed by Certified Nurse Assistant 1 (CNA 1), fell , and sustained a fracture (broken bone) on the right hip. […]

• Actual harm, isolatedF689May 24, 2022

  Based on observation, interview, and record review, the facility failed to provide care and services to prevent accidents to one of three sampled residents (Resident 1) by failing to ensure: 1. Certified Nursing Assistant 1 (CNA 1) used the mechanical lift (a device used by staff to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from a bed to a wheelchair with the assistance of another staff, as indicated in the facility's policy and procedure. 2. […]

• Actual harm, isolatedF684Feb 13, 2022

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 performed cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) as indicated in the facility's Emergency Procedure-Cardiopulmonary Resuscitation, policy and procedure, to Resident 1 who was full code (a patient who chooses to be resuscitated if he or she stops breathing of if the heart stops beating or wishes to have full treatment in life-threatening situations to do CPR) when Resident 1 was suddenly found to be unresponsive, not breathing,… […]