The Springs of Mt Vista

In the surveyor’s words

From the most serious findings on record at The Springs of Mt Vista, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF770Sep 27, 2024

  Based on observation, interview, and record review, the facility failed to ensure the laboratory waiver was renewed for 1 of 1 facility requiring a waiver to perform testing. Specifically, the facility Centers for Medical & Medicaid Services Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver (COW) was expired. The findings are: Review of a Centers for Medicare and Medicaid Services (CMS) CLIA brochure titled, How to obtain a CLIA Certificate, revealed a COW is issued to perform waived tests, defined as a lab test with insignificant risk of erroneous results. […]

• No harm, potential for more than minimal, widespreadF880Sep 27, 2024

  Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to maintain Legionella surveillance for 1 of 1 water management plan and maintain sanitary conditions for 1 of 1 resident unit refrigerator reviewed for infection control. Findings include: A review of the facility's undated policy but with a copyright date of 2022 titled Legionella Surveillance, indicated Legionella was a bacteria found in water that caused a serious type of pneumonia called Legionnaires' Disease. Legionella surveillance is one component of the facility's water management plan for reduction risk of bacteria in the facility's water system. […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure food stored in the facility's refrigerator, freezer, and dry storage were dated when received and/or opened, spices were discarded after a year, foods stored in opened boxes were in sealed bags, and perishable foods were accurately dated with the date prepared in 1 of 1 kitchen. The failed practice had the potential to affect 71 residents who received meals from the kitchen as documented on the Dietary Diet report provided by the Director of Nursing (DON) on 07/19/23 at 3:44 PM. The findings are: 1. On 07/17/23 at 11:24 AM, during the initial tour of the kitchen, the dry storage room, and the walk-in freezer the following observations were made: a. […]

• No harm, potential for more than minimal, widespreadF812Apr 22, 2022

  Based on observation, record review and interview, the facility failed to ensure the kitchen equipment, refrigerators, and walls were clean; the kitchen ceiling was maintained in safe clean condition; fans in the food prep area were clean; staff wore facial hair coverings while preparing and or serving food; food items stored in the freezer, refrigerator and dry storage room were sealed and dated to maintain freshness and prevent and potential cross contamination; leftover food items were promptly used or discarded; and expired food items were removed / discarded on or before the expiration or use by dates to prevent potential food borne illness; for residents who received meals from 1 of 1 kitchen. […]

• No harm, potential for more than minimal, widespreadF812Mar 5, 2021

  Based on observation, record review, and interview, the facility failed to ensure foods were properly stored in the dry storage area, the walk-in refrigerator, and the walk-in freezer; and failed to ensure 1 of 1 ice machine was maintained in a clean and sanitary manner, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 65 residents who received meals from the kitchen, according to a list provided by the Administrator on 3/4/2021. The findings are: 1. On 3/1/2021 at 10:50 a.m., one bag of macaroni pasta was stored on a shelf in the dry storage. The bag of pasta was opened and was not resealed. a. On 3/1/2021 at 10:51 a.m., one bag of spiral pasta was stored on a shelf in the dry storage area. […]