Mountain Vista Health Center

F-F609: failure to report an injury of unknown origin and

F-F658: failure to monitor an injury per professional standards).

III. Leadership efforts

The facility nursing home administrator (NHA) had been out on administrative leave since 1/31/25 (seven weeks as of 3/20/25), leaving the facility without a state-licensed administrator to manage the facility's day-to-day operations, particularly the management of incident reporting and investigations. The NHA had

the responsibility to lead investigations for allegations of abuse to ensure compliance with identifying potential abuse; responding to an allegation of abuse; preventing ongoing abuse; and reporting abuse to the proper authority, all in a timely manner.

IV. Staff interviews

The director of nursing (DON) was interviewed on 3/19/25 at 12:05 p.m. The DON said the NHA was on administrative leave and she did not know if he was coming back to his position. The DON said the corporate consultants had been providing additional guidance in his absence, but she had taken on the role of abuse incident coordinator. The DON said it was difficult to manage the role of abuse incident coordinator, with all of her other duties.

The DON and the corporate nurse consult (CNC) were interviewed on 3/20/25 at 3:11 p.m. The CNC said there was not currently an interim NHA with a state license filling in in the absence of the facility's NHA; however, the corporate office was looking for an interim NHA. The CNC said in the meantime, the CNC and other corporate leadership offered the DON and facility staff support onsite and remotely.

The DON said she was acting as the facility abuse coordinator in the absence of the NHA, with assistance from the unit managers and social services staff, to determine needed interventions and complete abuse investigations. The DON said she would be glad to have someone take over the role of abuse coordinator because it was a lot to manage with her clinical duties.

The DON said she did not report Resident #7's injury of unknown origin because she knew the resident and even though no one witnessed the injury occur, she assumed the injury was self-inflicted.

The DON said she was not well-versed in the regulatory requirements for reporting and investigating abuse and was not able to give details on all types of incidents that needed to be reported. The DON said she did not know that injuries of unknown origin needed to be reported when the source of the injury was not observed, the injury could not be explained, and the injury was suspicious because of the extent of the injury or the location of the injury.

V. Follow up

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 065015 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065015 B. Wing 03/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain Vista Health Center 4800 Tabor St Wheat Ridge, CO 80033

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 The facility hired a full-time interim nursing home administrator (INHA) on 3/24/25. The INHA had an active State NHA license and prior experience in the industry Level of Harm - Minimal harm or potential for actual harm -An interview with the INHA revealed that she and the CNC had already started training with leadership staff

on the components of compliance for abuse identification, reporting, prevention and investigating. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 065015