Mountain Vista Health Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Environmental Deficiencies

Keep all essential equipment working safely.

A complaint survey, prompted by #CO2608445, Incident #1926122, Incident #2607330 and Incident #2626417 was completed on 10/7/25 to 12/9/25. One deficiency was cited. The actual Survey date was 10/9/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/9/25. Based on record review and interviews, the facility failed to investigate and document incidents of physical abuse involving two (#2 and #3) of three residents reviewed out of eight sample residents. Specifically, the facility failed to conduct a thorough investigation of physical abuse involving Resident #3 and Resident #2. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, dated October 2024, was provided by the nursing home administrator (NHA) on 10/8/25 at 9:52 a.m. via email. It revealed in pertinent part,“An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.“Written procedures for investigations include: identifying staff responsible for the investigation; investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and, providing complete and thorough documentation of the investigation.“Analyzing the occurrence(s) to determine why abuse, neglect, occurred, and what changes are needed to prevent further occurrences;“Training of staff on changes made and demonstration of staff competency after training is implemented;“Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and,“Identification of staff responsible for monitoring the implementation of the plan.”II. Incident of physical abuse between Resident #2 and Resident #3 on 8/8/25A. Facility investigationThe 8/8/25 facility investigation documented Resident #2 and Resident #3 kicked each other while in the dining room. The investigation documented the residents were separated. The investigation documented Resident #2 had a history of aggressive behaviors with three prior incidents in the facil..

A complaint survey, prompted by #CO39932 was conducted on 6/11/25. One deficiency was cited. Based on observations, record reviews, and interviews, the facility failed to properly prepare and store food and to maintain sanitary conditions in the main kitchen.Specifically, the facility failed to:-Ensure the main kitchen was clean and sanitary;-Ensure damaged cans were disposed of; and,-Ensure food was labeled and dated.The findings include:I. Ensure the main kitchen was clean and sanitary A. Professional referenceThe Colorado Retail Food Establishment Regulations (3/14/24), retrieved on 6/18/25 read in pertinent part,"Nonfood-contact surfaces shall be constructed of approved materials, in good repair, and be easily maintained in a clean and sanitary condition."Equipment food-contact surfaces and utensils shall be clean to sight and touch. Food contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other solid accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (Chapter 4)"Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers." (Chapter 5)B. ObservationsThe initial main kitchen tour was conducted on 6/11/25 at 11:00 a.m and the following was observed:-The vents above the stove were greasy and dusty, there was a sticker on the vents that indicated they were serviced on 2/27/25; -There was a yellow puddle of an unidentifiable liquid under the shelf in the dry storage room;- The used aprons were stored next to clean glassware and dishes;-The shelves were covered with light, white dust and felt sticky upon touch;-There was a dark grey trashcan in the preparation area that had no lid and the outside of the trashcan was covered with unknown white splatters and dried on food; -The shelf under the preparation table had dried on food and it was greasy;-The radio, paper towel dispenser, waffle maker, food cart and the food processor h..

A complaint survey, #CO39544, Incident #39481, Incident #39482, Incident #39582 and Incident #39583 was conducted on 3/19/25 to 3/24/25. Five deficiencies were cited. Based on observation, record review and interviews, the facility failed to promote dignity and respect for one (#12) of three residents out of 14 total sample residents. Specifically, the facility failed to promote dignity and respect by sitting with the Resident #12 at the dining table and providing meal assistance in a dignified manner. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL' s) policy and procedure, dated 2024, was provided by the corporate nurse consultant (CNC) on 3/25/25 at 12:28 p.m. It read in pertinent part, "The facility will, based on the resident' s comprehensive assessment and consistent with the resident' s needs and choices, .. Based on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychosocial well-being for two (#7 and #14) of three residents reviewed for dementia care out of 14 sample residents. Specifically, the facility failed to develop and implement effective dementia management-focused interventions to prevent Resident #7 and Resident #14 from wandering into other residents' rooms. Findings include: I. Facility policy and procedure The Dementia Care policy and procedure, undated, was prov.. 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 injur.. Based on record review and interviews, the facility failed to ensure one (#1) of two residents out of five sample residents received treatment and care for optimal skin condition of a pressure wound and injury of unknown origin, in accordance with professional standards of practice. Specifically, the facility failed to:-Develop a care plan for treating Resident #1' s moisture-associated skin damage (MASD) and preventing pressure injury due to immobility;-Reassess alternative methods of providing Resident #1' s pressure-relieving interventions when the resident refused offers to be repositioned; and, -Reassess treatment methods and implement alternative interventions when .. Based on record review and interviews, the facility failed to report alleged violations of potential abuse, neglect, exploitation or mistreatment and injuries of unknown origin to the state oversight agency in accordance with state laws for two of five alleged abuse violations. Specifically, the facility failed to:-Timely report an allegation of sexual abuse by Resident #6 towards Resident #4, Resident #5, Resident #2 and Resident #3 to the State Agency; and,-Report Resident #7' s injury of unknown origin to the State Agency. Findings include: I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy and procedure, dated October 2024, was received from the director of nursin..

A complaint survey, prompted by Incident #38918, Incident #38952, Incident #39147 and Incident #39149 was conducted on 2/20/25 to 2/24/25. One deficiency was cited. Based on record review and interviews, the facility failed to investigate an allegation of physical abuse for two (#10 and #11) of six residents reviewed out of 11 sample residents. Specifically, the facility failed to thoroughly investigate alleged abuse between Resident #10 and Resident #11.Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, dated October 2024, was provided by the director of nursing (DON) on 2/25/25 at 1:48 p.m. via email. It read in pertinent part,"Abuse is defined as the willful infliction of injury with resulting physical harm, pain or mental anguish, which can include resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. "Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. "Alleged violation is a situation or occurrence that is observed or reported by staff, residents, relatives, visitors or others but has not yet been investigated and, if verified, could be indication of noncompliance with the federal requirements related to abuse."The facility will develop and implement written policies and procedures that establish policies and procedures to investigate any such allegations."An immediate investigation is warranted when suspicion, or reports, of abuse occur."Written procedures for investigations include identifying staff responsible for the investigation, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, focusing the investigation on determining if the abuse occurred, the extent, and cause and providing complete and thorough documentation of the investigation."II. Resident #10 - assailant A. Resident statusResident #10, age greater than 65, was admitted on 3/15/19. According to the February 2025 computerized physician orders (CPO), diagnoses included Alzheimer' s disease and dementia with behavioral disturbance.The 12/9/2..

A survey prompted by complaint #CO37416, #CO38185, #CO38252 AND Incident #38167 was conducted on 11/20/24. One deficiency was cited. 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 4/3/24 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 4/6/24. No injuries were reported.-However, the staff did not conduct a full skin assessment to determine if other injuries were present.On 4/8/24, a progress note revealed that the resident had a faded yellow bruise to the left shoulder, hip, and a yellow, faded bruise to the left eye. On 4/12/24, a weekly skin assessment was conducted following a shower. It revealed a green/yellow bruise to the left side of the face, shoulder and breast. An abnormal protrusion to the clavicle (collarbone) was noted. -However, since there were no weekly skin assessments conducted since the original incident on 4/3/24, the date and origin of the clavicle injury were not identified.Due to the facility' s failure to ensure a complete assessment after identifying an injury of unknown origin on 4/3/24, Resident #1 experienced a delay in care for her clavicle injury which was not discovered until an x-ray was performed on 4/13/24 and revealed a fracture.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/20/24, resulting in the deficiency being cited as past noncompliance with a correction date of 7/31/24.I. Incident and injuries of unknown origin between 4/3/24 and 4/12/24Resident #1 sustained an injury of unknown origin on 4/3/24 and a fall on 4/6/24. A full skin assessment documenting the resident' s injuries was not performed until 4/12/24 (nine days later).Due to the facility' s failure, th..