Mountain Vista Manor CORP

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. During an environmental inspection of the facility, the Compliance Officer observed a door leading to a backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area, however, the device was not active. 3. In an interview, E1 reported that the device was only turned on at night, and that it would make too much noise if it was on during the day. E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During the facility tour, the Compliance Officer observed a plastic bin in the unlocked refrigerator containing three boxes of "Latanoprost". 2. In an interview, E1 acknowledged medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. Review of the May 2024 personnel schedule revealed two shifts; 6AM-6PM (day shift) and 6PM-6AM (night shift). 2. Review of the facility's employee disaster drills revealed the most current disaster drill conducted October 15, 2023 on the day shift. No other employee disaster drill was available after October 15, 2023. 3. In an interview, E1 acknowledged the employee disaster drills were not conducted on each shift at least once every three months.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. The deficient practice posed a risk if employees were unable to implement the evacuation plan. Findings include: 1. Review of the facility's employee and resident evacuation drills revealed the most current drill conducted July 6, 2023. No other employee and resident evacuation drills were available after July 6, 2023. 2. In an interview, E1 acknowledged the employee and resident evacuation drills were not conducted at least once every six months.