Mesa View Senior Living

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents or their representative had properly completed Out-of-Hospital Do-Not-Resuscitate(OOH-DNR) form which requires the document to be properly completed and signed, including the notary's date of completion for 4 (Residents #2, # 4, #8, and #11) of 17 residents reviewed for advanced directives. Residents #2, # 4, #8, and #11's DNR form in their record was missing the date of when the notary signed the form. This failure could place residents at risk of receiving medical treatment inconsistent with their or their legal representatives expressed wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 4 kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated in House A kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #4 and #32) of 17 Residents reviewed for comprehensive care plans. -The facility failed to address the use of oxygen in Resident #4 and Resident #32's care plans. This failure could result in residents not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #32) of 17 residents reviewed for respiratory care. -Resident #32 was not receiving oxygen at the correct dose. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of biologicals for 1 of 7 insulins reviewed to meet the needs of each resident. The House B medication cart had an inulin bottle that expired according to the date documented on the bottle of when it was opened. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure that all foods served to residents were labeled and dated as to when they were received and/or opened. The facility failed to ensure food packaging was properly closed and not open to air. This failure could place residents at risk of food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 120 days (8/24/24) of RN schedules reviewed for RN nurse coverage. The facility failed to ensure there were at least 8 hours of RN coverage on August 24, 2024. This failure could place residents at risk of receiving improper care in the event of an emergency and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 of 3 (Sunset House ) medication carts observed for . The facility failed to dispose of Bisacodyl Suppositories that expired on 11-2024 in the medication cart located at the Sunset House. This failure could place residents receiving medications at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or receiving expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 5 residents (Resident #1) reviewed for medication administration, in that: CMA B administered medications to Resident #1 via crushed medications in yogurt with whipped cream and left Resident #1 unattended with the yogurt/medication mix. This was stated by CMA B during conversation with Investigator on 7/8/24 at facility and a written statement by CMA B. This failure can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization.

Inspectors wroteBased on observation, interviews and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 households (Bldg A and Building E) observed for sanitation and COVID protocols in that: Bldg A and Bldg E did not follow infection control policies related to sanitation and COVID- 19 transmission-based precautions for households and residents that were COVID- 19 positive. This failure could place residents at risk for infections, contamination, physical decline, and hospitalization.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 4 kitchens observed. Staff members failed to practice hand hygiene between plates during lunch service and wear hairnets while in the kitchen. This failure can place residents at risk for infection and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make prompt efforts to resolve grievances for 9 of 12 anonymous residents reviewed for resident rights. The facility did not make prompt efforts to follow through on grievances made for staff being on the phone or proper food temperatures when served. This failure could place residents at risk of weight loss, emotional distress, and decreased quality of life. Findings Included: An observation on 11/14/23 at 10:50 AM showed [NAME] D observed in Bldg E talking to someone on the phone via a pink headset that staff was wearing on head. Residents were present after a Resident Council meeting ended in the dining room. An observation on 11/14/23 at 10:55 AM showed [NAME] D returned to kitchen in Bldg E, spoke in Spanish, tapped the left side of the pink headset. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to complete a MDS assessment every 92 day or within a timely manner for 3 (Residents #12, #18, and #37) of 12 residents reviewed for MDS assessments The facility failed to initiate a MDS assessment or complete an MDS assessment within 14 days after the ARD date for Residents #12, #18 and #37. This failure can place residents at risk of proper needs not being met, quality of care, assistive devices, and accuracy of assistance needed with activities of daily living.

Inspectors wroteBased on , interviews, and record reviews, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 7 (Residents #1, #3, #11, #12, #18, #25, and #37) of 12 residents reviewed for care plans. Residents #1, #3, #11, #12, #18, #25, and #37 did not have a comprehensive care plan completed 7 days after a comprehensive assessment. This failure places residents at risk for substandard quality of care, accuracy of needs, and assistance with activities of daily living.

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 4 (Prairie House medication room, Cottonwood House medication room, Cottonwood House medication cart, and Sunset House medication room) of 6 medication storage areas reviewed for medication storage. The Prairie House Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Cottonwood Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Sunset Household Medication room refrigerator had medications that had been stored out of recommended storage temperatures. The Cottonwood Household Medication cart contained 3 insulin pens that had no medication labels. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a significant change of condition assessment within 14 days of determining or should have determined that there had been a significant changed in a resident physical or mental condition for 1 (Resident #13) of 12 residents review for significant changes of condition. The facility failed to complete a significant change of condition MDS assessment when Resident #13 was admitted to hospice. This failure to ensure comprehensive and accurate assessments are completed could affect residents by placing them at risk for not receiving correct care and services leading to deterioration in their condition.