Mountain View Care Center

Inspectors wroteBased on recorded review, interview and document review the facility failed to ensure physician orders were followed for the treatment of hypoglycemia (low blood sugar) and the physician notified of a change of condition for 1 of 20 sampled residents (Resident 52). The deficient practice had the potential to lead to worsened symptoms of hypoglycemia, hospitalization, or even death.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a pharmacist's recommendation for a gradual dose reduction (GDR) was act upon for 1 of 20 sampled residents (Resident 30). The deficient practice had the potential for significant side effects including drowsiness, blurred vision, fatigue, trouble sleeping, and changes in mood.

Inspectors wroteBased on observation, record review, interview, and document review, the facility failed to ensure the medication error rate was less than five percent (%) resulted in a medication error rate of 6.67%. This deficient practice had the potential to put the resident at risk for adverse drug reactions, ineffective treatment, and compromised health outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1) safe and sanitary medication administration practices for 1 of 3 residents (Resident 61) during the medication pass observation, and 2) the Water Management Program included all requirements to prevent the growth and spread of Legionella. This deficient practice had the potential to compromise resident safety by increasing the risk of infection and cross contamination during medication administration, and exposure to waterborne pathogens.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure residents' tube feeding (TF) orders were followed and completely delivered as ordered for 3 of 5 sampled residents (Residents 54, 48, and 11). The deficient practice could have led to a potential risk of malnutrition, dehydration, and inadequate caloric intake, compromising residents' health and increasing susceptibility to further medical complications.

Inspectors wroteBased on observation and interview, the facility failed to label, and date open stored food products, and maintain sanitary conditions in the kitchen. The deficient practice could potentially expose residents to foodborne illnesses.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure: 1) Signage for Enhanced Barrier Precaution (EBP) was posted for a resident with a urinary catheter and an unstageable wound, and personal protective equipment (PPE) was available (Resident 82), 2) Gown was used by staff when providing direct care to residents on precautions, and hand hygiene was performed after removing the used gloves (Resident 63); and 3) a policy was in place regarding the reuse of gowns after use. This deficient practice had the potential to increase the risk of cross-contamination, the spread of healthcare-associated infections, and compromise infection control measures.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to develop a baseline care plan for the use of an indwelling Foley catheter within 48 hours of a resident's admission for 1 of 20 sampled residents (Resident 82). This deficient practice posed potential risks, including increased likelihood of infection, catheter blockage, tissue damage, and inadequate monitoring of urinary output.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to develop a comprehensive care plan for: 1) fall prevention for a resident at risk for fall (Resident #56), 2) and medication self-administration (Resident #79). The deficient practice had the potential to deprive the residents for receiving necessary care to prevent health complications.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the resident's Foley catheter was properly assessed and the correct Foley size was inserted or clarified for 1 of 20 sampled residents (Resident 82). This deficient practice had the potential to increase the risk of discomfort or pain, or urinary tract injury and complications.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to; 1) monitor weights for a resident with prescribed weight gain (Resident #67), and 2) ensure vulnerable residents' tube feeding free water flush (FWF) orders were followed and completely delivered as ordered for 1 of 5 sampled residents receiving continue hydration via gastrostomy tube (Resident #11). The deficient practice could have led to a potential risk of dehydration, electrolyte imbalance, kidney complications, and increased susceptibility to further health issues, thereby compromising the residents' overall well-being and recovery.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain essential kitchen equipment in good repair. The deficient practice had the potential to affect the quality and safety of the ice produced, and the lack of reliable temperature monitoring posed a risk to food safety, as it prevents accurate assessment of the freezer's ability to maintain appropriate food storage temperatures.

Inspectors wroteBased on interviews, record review and document review the facility failed to ensure a dependent, non-verbal resident was not left in a wet brief for an extended period of time for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for worsening of health conditions and psychosocial harm.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a person-centered care plan was developed and implemented for a resident with limited English proficiency (LEP) for 1 of 19 sampled residents (Resident 74). The deficient practice placed the resident at risk for feeling isolated and unable to express needs impacting quality of life.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a physician's order for a splint device was carried out for 1 of 19 sampled residents (Resident 46). The deficient practice placed the resident at risk for worsening contracture of the right hand.

Inspectors wroteBased on observations, interviews, record review, and document review the facility failed to ensure a physician order for continuous use of Oxygen was followed for 1 of 19 sampled residents (Resident 53). The deficient practice had the potential for adverse outcomes for a resident requiring use of Oxygen.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a physician's order was obtained in the administration of a medication for one unsampled resident (Resident 10). The deficient practice had the potential for the resident not receiving the physician ordered medication regimen or non-pharmacological interventions for pain management.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a multi-dose Insulin pen stored in 1 of 3 medication carts inspected was dated when opened (200 Hall Medication Cart). The deficient practice had the potential for the resident to receive an expired medication.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure items in a refrigerator were not expired and food in the freezer was labeled and dated. The deficient practice had the potential to result in residents receiving outdated food items increasing the risk of food-borne illness.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure training was provided to employees regarding the facility's language line or interpretation services for 1 of 19 residents (Resident 74). The deficient practice had the potential to make residents with limited English proficiency (LEP) feel isolated and unable to express needs impacting their quality of life.