Mountain Vista Health Center

In the surveyor’s words

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

• Actual harm, isolatedF600Nov 20, 2024

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of 10 sample residents was free from neglect. Resident #1 suffered an injury of unknown origin to the left forehead, a hematoma (a localized swelling of pooled blood due to injury or trauma), on [DATE] following a shower provided by hospice certified nurse aide (CNA) #1. The resident's son was notified of the forehead hematoma at 3:06 p.m., but the staff did not conduct a full skin assessment on the resident afterward to determine if other injuries were present. Resident #1 sustained a fall three days later, on [DATE]. […]

• Actual harm, isolatedF692Mar 20, 2024

  Based on observations, record review and interviews, the facility failed to two (#87 and #92) of three residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 34 sample residents. Resident #87 was admitted on [DATE]. Her admission weight was 113.8 pounds (lbs). The resident maintained a weight between 113 lbs and 118 lbs between January 2023 and January 2024. The resident lost 12.3 pounds between 1/4/24 and 2/15/24. The facility did not weigh the resident monthly despite a physician's order for monthly weights. The registered dietitian (RD) recommended weekly weights and weights were not consistently obtained on a weekly basis. The resident had poor meal intake and refused meals. […]

• Actual harm, isolatedF689Nov 1, 2023

  Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#1) of three residents out of three sample residents reviewed for accident hazards. The facility failed to ensure measures were in place to prevent Resident #1's fall with injuries. Resident #1 was identified as a high fall risk on her 8/6/23 Fall Risk Assessment and the 8/9/23 minimum data set (MDS) assessment documented Resident #1 required extensive assistance of two persons for bed mobility, transfers, toileting and bathing. Resident #1's care plan prior to her fall did not have interventions that included assistance from two people for bed mobility, transfer, toileting and bathing. […]

• Actual harm, isolatedF550Mar 23, 2022

  Based on interviews and record review, the facility failed to ensure residents on two out of three units had the right to a dignified existence. Specifically, the facility failed to ensure residents experienced a dignified living experience by answering the call lights timely to include Residents #6, Resident #10, Resident #5 and Resident #15 who required extensive assistance or total assistance with toileting. From the untimely response to the call light, Resident #6 expressed feelings of dehumanization. Resident #6 said she felt very embarrassed and humiliated when she had an accident waiting for her call light to be answered. […]

• No harm, potential for more than minimal, widespreadF835Mar 24, 2025

  Based on record review and interviews, the facility failed to ensure facility resources were administered in a manner that allowed its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. Specifically, the facility failed to: -Provide sufficient leadership to address and or avoid multiple concerns; -Prevent, report and fully investigate allegations of abuse timely to provide immediate protections to residents at risk of being victimized and re-victimized; -Report an injury of unknown origin in a timely manner so that an accurate timeline of events could be established and the injury could be effectively treated and monitored; and, -Implement effective interventions to… […]