ELLENSBURG, WA - Federal inspectors documented serious medication safety failures at Mountain View Post Acute that put a heart transplant recipient at significant risk when staff repeatedly administered a critical anti-rejection medication outside safe timing parameters.
Life-Threatening Medication Timing Errors
The most concerning violation involved Tacrolimus, an immunosuppressive medication that prevents the body from rejecting transplanted organs. This medication requires precise timing to maintain steady blood levels and prevent organ rejection.
Inspection records show that between December 31, 2024, and January 13, 2025, nursing staff administered the medication incorrectly 12 out of 27 times - nearly half of all doses. The timing errors included:
- One dose given 4 hours and 4 minutes late (January 13, 1:04 AM) - Another dose administered 2 hours and 35 minutes late (January 12, 11:35 AM) - Multiple doses given 40-53 minutes outside the prescribed schedule
The medication administration record (MAR) contained no special instructions alerting nurses to the critical timing requirements for this life-saving drug.
Medical Significance of Timing Precision
Tacrolimus must be taken at precisely 12-hour intervals to maintain therapeutic blood levels. When doses are missed or delayed, blood levels drop below the effective range, increasing the risk that the patient's immune system will attack and reject the transplanted heart.
According to patient education materials referenced in the inspection, "Tacrolimus must be taken at the same time every day to keep steady levels of Tacrolimus in your blood." A transplant pharmacist interviewed during the inspection confirmed that doses not given 12 hours apart create "risk for organ transplant rejection."
Heart transplant recipients depend on immunosuppressive medications for survival. Any disruption in the medication schedule can trigger rejection episodes that may result in permanent organ damage or death.
Staff Unaware of Critical Requirements
During interviews, facility staff revealed they were unaware of the special handling requirements for this high-risk medication. The Licensed Practical Nurse responsible for administering the drug stated they were "unaware of any specific instructions or considerations" with Tacrolimus administration.
The Resident Care Manager confirmed there had been no communication with the patient's transplant team regarding proper administration protocols, and the critical timing instructions had not been added to the resident's medication record.
Multiple System Failures in Psychotropic Medication Management
Inspectors also documented failures in the facility's management of psychiatric medications affecting two residents. The facility failed to:
- Complete required movement assessments before starting antipsychotic medications - Establish resident-specific behavioral monitoring - Attempt non-medication interventions before prescribing psychiatric drugs - Obtain proper informed consent for psychotropic medications
One resident received Seroquel for insomnia, which pharmacy consultants noted was inappropriate use of an antipsychotic medication. Another resident was prescribed multiple psychiatric medications without proper behavioral monitoring or assessment protocols in place.
Infection Control Lapses Endanger Respiratory Patients
The facility failed to maintain basic infection control standards for oxygen therapy equipment. Inspectors found oxygen concentrator filters on three different patients covered with "thick layers of dust, dirt and hair" that impeded proper function.
These filters are supposed to be changed weekly according to physician orders, but staff were not following the prescribed maintenance schedule. Dirty filters reduce the device's ability to filter contaminants from the air, potentially exposing patients with respiratory conditions to harmful particles and pathogens.
One patient's oxygen humidifier and tubing were stored on the floor rather than in proper containers, creating additional contamination risks. Staff acknowledged this violated infection control protocols but stated they lacked proper equipment to store the devices appropriately.
Food Safety and Quality Concerns
Multiple residents complained about receiving cold, unappetizing meals. One resident with diabetes and malnutrition stated, "The food is terrible here. It was often served cold which was unappetizing to them and made it difficult to eat."
During meal observations, inspectors documented: - Cold, hard eggs and grayish potato patties served for breakfast - Overcooked, brownish broccoli that was "soft and brownish in color" - Pureed meals described by residents as "disgusting and not appetizing" - Rice described as "flavorless with a gummy consistency"
Nursing assistants explained that residents in the east dining room received meals last, often 15 minutes or more after food left the kitchen, resulting in cold temperatures by the time meals reached patients.
Administrative and Documentation Failures
The facility failed to maintain required daily nursing staff postings that inform residents and families about current staffing levels. For three days during the inspection period, no staffing information was available in areas accessible to visitors.
Staff members also allowed residents with severe cognitive impairment to sign binding arbitration agreements without verifying their capacity to understand the legal implications. Two residents with "severely impaired cognition" signed legal contracts that waived their right to jury trials in disputes with the facility.
Vaccine Program Breakdown
The facility's immunization program was described by staff as "broken" during a local influenza outbreak. Two residents who requested flu vaccines had not received them, with one resident stating they "had not been approached to consent to receive the Influenza vaccine which they would accept."
The lack of proper vaccine administration occurred during what local health officials confirmed was an active influenza outbreak in the community.
Facility Environment and Safety Issues
Inspectors documented widespread maintenance problems affecting resident safety and comfort:
- Floors with embedded dirt and grime that couldn't be removed by routine cleaning - Damaged heating units next to resident seating areas - Shower rooms with black tar-like substances embedded in tile grooves - Room temperature control problems leaving residents uncomfortably hot
The maintenance director acknowledged the facility "was old and in need of many repairs" but indicated no repair schedule was in place.
Regulatory Response and Implications
These violations occurred during a routine recertification survey at the facility located at 1050 E Mountain View in Ellensburg. The findings represent systemic failures in medication management, infection control, food service, and basic facility maintenance.
Federal regulations require nursing homes to ensure residents receive proper medication administration, maintain infection control standards, provide nutritious meals at proper temperatures, and maintain safe, clean environments. The documented violations suggest widespread breakdowns in these fundamental care requirements.
The facility's Director of Nursing acknowledged several of the problems, stating that medication monitoring systems and non-pharmacological interventions "were lost during their change of ownership transition and was still a discussion they were working on."
These inspection findings highlight the critical importance of proper medication management, particularly for residents with complex medical conditions requiring precision drug therapy. For heart transplant recipients and other vulnerable populations, even minor deviations from prescribed treatment protocols can have life-threatening consequences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prestige Post-acute & Rehab Ctr - Kittitas Vallley from 2025-01-14 including all violations, facility responses, and corrective action plans.
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