Montevista Rehabilitation and Skilled Care

In the surveyor’s words

From the most serious findings on record at Montevista Rehabilitation and Skilled Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 1, 2024

  A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 04/04/24 related to the facility's failure to provide adequate supervision to ensure a resident remained safe and free from elopement. The facility failed to provide adequate supervision and interventions to prevent the resident from exiting the facility and leaving the premises unsupervised. On 05/01/24 at 9:57 a.m., the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to provide adequate supervision to protect the resident and prevent elopement. […]

• Actual harm, isolatedF805Apr 2, 2024

  Based on record review and interview, the facility failed to ensure a resident received food prepared to meet the resident's needs, which resulted in hospitalization , for one (#1) of four residents reviewed for therapeutic diets. The administrator reported a census of 84 residents. Findings: A Menu Planning policy, dated 11/01/17, documented in part, .Nutrition Services will be responsible to prepare and serve the diet as ordered .Nursing staff will notify the NSM of needed consistency changes .Resident response to special and modified diets will be evaluated. Ineffective or inappropriate diets, including texture modifications, will be referred .to the attending physician, dietitian, and/or therapy department for evaluation . […]

• Actual harm, isolatedF697Jul 13, 2023

  Based on record review and interview, the facility failed to ensure a resident's pain was controlled for one (#95) of two sample residents were reviewed for pain. The facility failed to have a physician ordered pain medication available for the resident when they requested two separate doses at six hour intervals. The resident requested to go to the hospital due to uncontrolled pain. The Resident Census and Conditions of Residents form, dated 07/09/23, documented 91 residents resided in the facility. Findings: Res #95 had diagnoses which included CAD, HTN, MDRO, CVA, hemiplegia, diabetes mellitus, and MS. […]

• No harm, potential for more than minimal, widespreadF812Jul 13, 2023

  Based on observation, record review, and interview, the facility failed to ensure and maintain a sanitary kitchen. The facility failed to ensure: a. food products were properly stored, b. food service equipment was kept clean, and c. sanitary hand hygiene practices were implemented while handling food. The Resident Census and Conditions of Residents report, dated 07/09/23, documented 91 residents resided in the facility and three residents received tube feeding. Findings: The facility's Food Storage Nutrition Services policy, read in part, .air-tight containers or bags are used for all opened packages of food. […]

• No harm, potential for more than minimal, patternF635Mar 4, 2025

  Based on record review and interview, the facility failed to: a. verify and obtain clarification from the physician to determine how often to flush the cholecystostomy drain and to measure and record the drain output for 1 (#1) of one sampled resident with a cholecystostomy drain; and b. administer medications as physician ordered for 1 (#1) of 1 sampled resident reviewed for new admissions to the facility. The administrator reported 88 residents resided in the facility and had 47 new admits to the facility in the last 30 days. The administrator reported they currently had no cholecystostomy drains in the facility. Findings: 1. A performance checklist skill Managing Wound Drainage Evacuation policy, dated 2018, read in part, Recording and Reporting, 1. […]