Mountain View Care Center

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for two (2) of 58 resident rooms, and the main dining room, observed during the long-term care survey process. Dining room doors in disrepair. Rooms #209 and #210 were in disrepair. Resident Identifiers: #52, 65, 48 and 28. Facility Census: 109.

Inspectors wroteBased on record review, staff interviews, and resident interviews, the facility failed to ensure residents knew how to file a grievance, including anonymously if desired, and failed to adequately resolve resident grievances. This deficient practice was confirmed during the Resident Council Meeting and was a random opportunity for discovery. This had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifiers: #128, #55, #38, #129, #130, #63, #33. Facility census:109. Findings Include: a) Resident Council Meeting During the Resident Council Meeting on 06/02/26 at 2:10 PM, the Resident Council agreed that they did not know how to file a grievance in writing or anonymously. [...]

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to correctly interpret the results of abuse allegation investigations and prevent further potential abuse while an investigation was in progress. This was true for five (5) of six (6) residents sampled for abuse during the Long-Term Care survey process. Facility census: 109. Resident identifiers: #21, #8, #49, #74, and #70. a) Resident #21, #8, #49 A policy titled, Abuse reads, in the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident in writing of the reason for the transfer to the hospital and send a copy of the notice to the ombudsman. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for the care area of hospitalization. Resident Identifiers: #2, #11, and #9. Facility Census: 109.

Inspectors wroteBased on resident interview, record review, observation and staff interview the facility failed to develop and or implement the care plan for three (3) of sampled residents reviewed during the long term care survey process. For Resident #77 they failed to develop a care related to his feelings of being abandoned by his girlfriend. For Resident #6 they failed to implement her care plan related to her wheelchair cushion. Finally for Resident #98 they did not develop his care plan related to his discharge goals and preferences. Resident Identifiers: #77, #6, and #98. Facility Census: 109. a) Resident #77 During an interview with Resident #77 on 06/01/26 at 12:42 pm he stated his family abandoned him. Mostly his fiancee, with whom he lived. He stated, I have anxiety and depression and this is part of the reason I feel like that. [...]

Inspectors wroteBased on record review, staff interviews, and resident interviews, the facility failed to include incapacitated residents in care plan meetings, and failed to revise care plans regarding tube feeding and transfer status. This deficient practice was found true for (3) three of 35 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers: #11, #4, and #6. Facility Census: 109. a) Resident #6 A review of Resident #6's care plan found the following: Focus Statement: MAINTENANCE: (First and Last Name of Resident #6) is a long-term care resident and requires assistance with their ADL's related to chronic health conditions, muscle weakness, COPD, difficulty in walking, lack of coordination. Date Initiated: 12/14/2024 Goal: (First Name of Resident #6) will maintain her current level of function as able through review period Date Initiated: [...]

Inspectors wroteBased on record review, resident interviews, and staff interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. This deficient practice affected four (4) residents reviewed in the long-term care survey sample. Resident Identifiers: #1, #76, #6, and #116. Facility census: 109.

Inspectors wroteBased on record review, resident interviews, and staff interviews, the facility failed to provide Dialysis services in accordance with professional standards of practice. Resident #1 did not receive dinner meals when returning from Dialyses. Resident #6 did not receive timely transportation back from Dialyses. This failed practice was found true for (2) two of (2) two residents reviewed for Dialysis services during the Long-Term Care Survey Process. Resident identifier: #1. Facility Census: 109.

Inspectors wroteBased on observation, resident interview, record review and staff interview the facility failed to ensure each resident was provided with medically related social services. The facility failed to correctly interpret the results of abuse investigations. They failed to report all allegations of abuse in the required time frames. The facility failed to ensure residents knew how to file grievances and could do so anonymously. In addition they failed to ensure grievances were resolved timely once filed. The facility also failed to complete accurate social service assessments and trauma screens. They failed to provide discharge planning to short term care residents. They also failed to ensure all residents were invited to participate in their care plan meetings. They failed to ensure resident was afforded the right to formulate their own advance directives and to have those directives honored. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an account of all controlled drugs was maintained and periodically reconciled. The facility failed to ensure the controlled substance count was signed by the on-going and off-going nurses performing the count. The facility also failed to identify and investigate a possible drug diversion for Resident #98.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration each resident's preferences. This deficient practice was found during the dining observation. This deficient practice has the potential to affect more than a limited number of residents. Resident identifier: #13, #23, #68 and #89 . Facility census: 109.

Inspectors wroteBased on record review, resident interviews and staff interviews, the facility failed to ensure all food was temped before leaving the kitchen, to ensure safe food temperatures to prevent foodborne illness and an appetizing temperature of the food. The facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice was true for one (1) of one (1) meal tray tested throughout the survey process. This failed practice had the potential to affect more than a limited number residents. Resident identifier: #49, 12, 89, 44 and 65. Facility census:

Inspectors wroteBased on observation and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than a limited number of residents. Facility census: 109Findings include: a) Policy #ADM - 077 - Label and Dating Requirements states: Policy: All prepared, opened, or repackaged foods shall be labeled and dated to ensure proper rotation and safety. Purpose: To prevent spoilage and maintain compliance with sanitation standards. Procedure: Each container must be labeled with product name, preparation or open date, and discard date. b) Policy #ADM - 018 - Equipment Cleaning and Maintenance states: Policy: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to store and dispose of garbage and refuse properly. The lids for the trash cans located in the kitchen and the dish room were not on during two different observations of the kitchen during the survey process. This failed practice has the potential to affect more than a limited number of residents at the facility. Facility census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medical records were complete and accurate. This deficient practice had the potential to affect nine (9) of 35 residents reviewed in the long-term care survey sample. Resident Identifiers: #11, #12, #98, #94, #77, #76, #20 and #6. Facility census: 109.

Inspectors wroteBased on record review, staff interviews and resident interviews the facility failed to treat each resident with respect and dignity by not recognizing their individuality. This failed practice was found true for (2) two of (3) three residents reviewed for dignity during the Long-Term Care Survey. Resident identifiers: #88 and #101. Facility census: 109. Findings Include: a) Resident #88 During an interview on 06/02/26 at 3:10 PM, Resident #88, who has a Brief Interview for Mental Status (BIMS) score of 15 stated, Last night an agency CNA came into my room at 1:00 in the morning and woke me up and said she needed to put my name on my personal stuff. I told her no and to get out. That is ridiculous. I think she went into other rooms and did the same thing. [...]

Inspectors wroteBased on record review, observation, staff interview and resident interview, the facility failed to ensure a resident's call light was within reach. This was a random opportunity for discovery. Resident Identifier: #52. Facility Census: 109.

Inspectors wroteBased on record review and staff interview the facility failed to ensure all residents were afforded the opportunity to formulate their own advance directive and to have their wishes honored after an advance directive is formulated. This was true for two (2) of seven (7) residents reviewed for the care area of advance directives during the long term care survey process. Resident identifiers: #11 and #124. Facility Census: 109. a) Resident #11 A review of Resident #11's medical record on the morning of [DATE] found a physician determination of capacity completed by Resident #11's attending physician on [DATE]. This form indicated Resident #11 had capacity to make medical decisions. This was the most recent capacity form located in Resident #11's medical record. Further review of the medical record found a Physician Order for Scope of Treatment (POST) form dated [DATE]. [...]

Inspectors wroteBased on record review, family interview and staff interview the facility failed ensure Resident #63 maintained privacy of her medical record. The facility sent excerpts from the residents medical record to an out of state facility without the permission of the healthcare decision maker. This was true for one (1) of one (1) residents reviewed for the care area of privacy during the long term care survey process. Resident Identifier: 63. Facility Census: 109. a) Resident #63 On 06/02/26 at 8:28 am an interview with the Medical Power of Attorney (MPOA) for Resident #63 revealed that the facility sent excerpts of the medical record to another facility without the MPOA's permission. She stated, Things are better now but they did do that last year. A review of Resident #63's medical record found the following Social Service Progress note: -- Not Dated 05/07/25 ar 9:23 AM read as follows: [...]

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to ensure Resident #49 was free from abuse. This was true for one (1) of five (5) residents sampled for abuse during the Long-Term Care survey process. Census: 109 Resident identifier: #49a) Resident #49 A policy titled Resident-To-Resident Altercations defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. During an interview with Resident #49 on 06/03/26 at 3:40PM, she stated she was yelled at and called names over a man and it made me feel degraded. Upon further investigation, a nursing note dated 02/17/26 at 6:27 PM revealed, It was reported to this nurse that resident 94036643 verbally threatened to kick resident 94036540's but. [...]

Inspectors wroteBased on record review and staff interview the facility failed to implement their Abuse Investigation and Reporting policy. The policy indicated all allegations of abuse will be reported to required state agencies within two (2) hours of the incident. This was true for one (1) of nine (9) residents reviewed for the care area of abuse during the long term care survey process. Resident Identifier: #74 Facility Census: 109. Findings Included: a) Resident #74 A review of the facilities Abuse Investigation and Reporting policy found the following under the heading Reporting: . 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure all allegations of abuse are reported to required state agencies within two hours of the alleged incident. This was true for one (1) of nine (9) residents reviewed for the care area of abuse during the long term care process, Resident Identifiers:#74. Facility Census: 109. Findings Included: a) Resident #74 A review of a reportable incident dated 01/19/26 involving alleged victim Resident #74 and alleged perpertrator Resident #97. Under the section what was reported the following was wrote: (First and Last name of Resident #74) was sitting by nurses station (First name of Resident #97) he rolled by and reached between (First name of Resident #74's) legs and (First name of Resident #74) smacked his hands away CNA redirected the residents. The date and time of the incident was listed as 01/19/26 at 1:12 PM. [...]

Inspectors wroteBased on resident interview, record review and staff interview the facility failed to ensure Resident #77 received timely and adequate discharge planning when he indicated to facility staff it was his desire to return to the community. This was a random opportunity for discovery and was true for Resident #77. Resident Identifier: #77. Facility Census: 109. a) Resident #77 During an interview with Resident #77 in the afternoon of 06/01/26 he stated, I want to go home but I lived with my fiance and she don't want me there so I don't know what I will do. Resident #77 was admitted to the facility on [DATE]. A review of Resident #77's record found only one capacity statement which was completed on 04/07/26 which indicated the resident has capacity to make medical decisions. A review of Resident #77's Minimum Data Set with an Assessment Reference Date (ARD) of 03/02/26. Found Section Q. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to identify all mental disorders for Resident #99 on the Pre-admission Screening and Resident Review (PASSAR). This was true for one (1) of two (2) residents sampled for PASSAR during the Long-Term Care Survey Process. Census: 109 Resident identifier: #99Findings included: a) Resident #99 The diagnosis list for Resident #99 includes bipolar disorder on admission, however, bipolar disorder is not included on the PASARR.In an interview with Social Services #100 at 1:15 PM on 06/03/26, it was confirmed that Resident #99 had bipolar disorder on admission but it was not included on the PASARR.

Inspectors wroteBased on record review, and staff interview the facility failed to ensure a resident who is unable to perform their own activities of daily living is provided assistance with completing them. This was true for one (1) of residents reviewed for the care area of Activities of Daily living during the long term care survey process. Resident Identifier: #20. Facility Census: 109. Findings Included: a) Resident #20 A review of Resident #20's medical record found that she was scheduled to receive a shower and/or bed bath on Mondays and Thursdays on day shift. Resident identified she preferred to take a bed bath instead of a shower. A review of the bathing report from 03/09/26 through 06/09/26 found the following time frames when Resident #20 did not recieve her baths as required: 04/15/26 to 04/22/26 a total of seven (7) days between baths. [...]

Inspectors wroteBased on resident interview, record review, and staff interviews, the facility failed to ensure Resident #7 received glasses to maintain vision ability, furthermore, the facility failed to make payment for Resident #6's glasses in a timely manner to make sure she received them. This was true for two (2) of two (2) residents sampled for vision. Census: 109. Resident identifiers: #7, #6. a) Resident #7 On initial interview on 06/01/26 at 1:00PM, Resident #7 stated he went to the eye doctor a month or so ago, but never got his glasses. In an interview with Social Services #100 at 11:55 AM on 06/02/26, she stated, I don't know anything about it. As far as I know, they [Resident's glasses] could be sitting at that doctor's office. At 12:00 PM on 06/02/26, the Director of Nursing (DON) stated she did not know anything about new glasses, but she would check into everything. [...]

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services to promote healing, and prevent new ulcers from developing by not removing the equipment that caused the pressure ulcer. This failed practice was found true for (1) one of (2) two residents reviewed for pressure ulcers during the Long-Term Care Survey Process. Resident identifier #12. Facility Census 109. Findings Include:a) Resident #12During the initial interview on 06/01/26 at 2:15 PM, Resident #12 stated, I have sores on my left and one on my butt. I think they take good care of them. The one on my left foot comes from this trapeze bar base. They were supposed to take it out but have not done it yet. The observation showed that the trapeze bar was in place. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health. This was true for two (2) of Two (2) residents reviewed related to foot health. Resident Identifiers: Resident #98 and #57. Facility Census: 109. a) Resident #98 A review of Resident #98's hospital Discharge summary, dated [DATE] indicated the resident was to follow up with the podiatrist in two (2) to four (4) weeks regarding black spots on his toes. On 06/02/26 the facility was asked to provide the surveyor a copy of this consult because it could not be located in the medical record. Nurse Consultant #131 confirmed on 06/03/26 that Resident #98 had not been to a podiatrist; [...]

Inspectors wroteBased on observation, resident interview, record review, and staff order, the facility failed to provide oxygen services within accepted standards of practice. The physician's orders for the supplemental oxygen flow rate was not followed. This deficient practice had the potential to affect one (1) of one (1) residents reviwed for the care area of oxygen. Resident Identifier: #69. Facility Census: 109.

Inspectors wroteBased on record review and staff interview the facility failed to ensure they had a Registered Nurse (RN) for eight (8) consecutive hours daily. This failed practice has the potential to effect more than an isolated number of residents currently residing in the facility. Facility Census: 109. A review of the facility's hours per patient day (HPPD) found they had 4.33 hours of RN coverage for 03/22/26. An interview with the Nursing Home Administrator (NHA) on 06/03/26 at 1:30 PM confirmed they did not meet the eight (8) hour requirement on 03/22/26.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to follow accepted standards of practice for medication labeling and storage. A multi-use vial of tuberculin purified protein derivative (PPD) had been in use longer than the time period recommended by the manufacturer. This was a random opportunity for discovery. Facility Census: 109.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure residents received dental services to meet their needs. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of dental services. Resident Identifiers: #4 and #26. Facility census: 109.

Inspectors wroteBased on Resident Interview, record review, observation and staff interview the facility failed to ensure Resident #20's food preferences were identified and honored as required. This was a random opportunity for discovery during the long term care survey process. Resident Identifier: #20. Facility Census: 109. a) Resident #20 During an interview on 06/01/26 Resident #20 was asked how the food at the facility was she stated, The food sucks. I am a vegetarian and get meat constantly. I have told them this for years. A review of Resident #20's medical record found a quarterly dietary profile dated 05/15/25. This was the most recent dietary profile in the medical record. This dietary profiled failed to identify the fact the resident does not like to eat meat. The dislikes section was left blank. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to offer residents pneumococcal vaccinations within accepted standards of practice. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of vaccinations. Resident Identifier: #76. Facility Census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to offer residents COVID-19 vaccinations within accepted standards of practice. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of vaccinations. Resident Identifiers: #11 and #24. Facility Census: 109.

Inspectors wroteBased on staff interview, resident interview, observation and record review, the facility failed to ensure menus were being followed, prepared in advanced and meet the resident's nutritional needs. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 106.

Inspectors wroteBased on resident interview, record review and observation, the facility failed to ensure the residents were served food that was palatable, attractive and at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. Resident Identifier: #86. Facility Census: 106.

Inspectors wroteBased on staff interview, observation and record review, the facility failed to ensure food was prepared and served in a manner that prevents food borne illness to the residents. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY.

Inspectors wroteThe facility failed to ensure residents heating, ventilation and air conditioning (HVAC) filter was free of debris. This was true for one (1) of six (6) HVAC units observed on the A Hall. Room identifier: 126-2. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to assess and review significant weight loss and failed to obtain weekly weights per recommendation of Registered Dietician and the risk management. The facility failed to assess and provide care to a resident with significant weight loss. This deficient practice was identified for one(1) out of three(3) residents with reported weight losses. Resident identifier #28. Facility census:

Inspectors wroteBased on observation, record review and staff interview, the facility failed to prepare food in the form to meet the individual needs of the resident as ordered by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #71. Facility Census: 106.

Inspectors wroteBased on record review and observation , the facility failed to provide drinks consistent with the resident's needs and diet order. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #39. Facility Census: 106.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to provide each resident with a nourishing diet in a form prepared to meet their individual needs. This failed practice created an immediate jeopardy sitaution. There was an immediate risk of choking for residents who were supposed to be served mechanical soft diets. This immediate jeopardy situation had the potentail to affect more than an isolated number of residents. Resident identifiers: #86, #42, #36, #48, #19, #57, #53, #16, #60, #75 and #7. Facility census: 106.

Inspectors wroteBased on observation and staff interview the facility failed to ensure a dignified dining experience. This was a random opportunity for discovery. Resident identifiers: #85, #547, #42. Facility census: #106.

Inspectors wroteBased on Resident Council meeting, record review, and staff interview the facility failed to act promptly upon the grievances/concerns from Resident Council. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents during the Long-Term Care Survey Process. Facility census: 106.

Inspectors wroteBased on resident council interview, observation and staff interview the facility failed to have the results from the last standard survey posted in a place easily accessible by residents. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents during the Long-Term Care Survey Process. Facility census: 106. Findings Include: a) Resident Council During the Resident Council (RC) Meeting on 02/18/25 at 2:00 PM, the RC as a whole said that they did not know they had access to the findings from the last standard survey. During an interview and observation on 02/18/25 at 3:45 PM, at the desk at the front door, The Administrator pulled a book out from behind the desk and stated, It usually sits on the desk not behind it. The Administrator then looked at Receptionist #78 and stated, This book has to stay right here. [...]

Inspectors wroteBased on observations and staff and resident interviews, the facility failed to ensure a safe, clean, comfortable, homelike environment by not cleaning and sanitizing Resident #10's wheelchair, cleaning the kitchen ceiling and exhaust fan and cleaning the shower room's ceiling and peeling paint. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier: #10. Facility census: 106.

Inspectors wroteBased on observation and staff interviews the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: #8. Facility Census: #106.

Inspectors wroteBased on record review and resident and staff interview, the facility failed to deploy sufficient nursing staff in order to meet resident needs. This has the potential to affect more than an isolated number of residents residing in the facility. Facility census: 106.

Inspectors wroteBased on record review, staff interview and observation the facility failed to ensure residents were receiving food in the amount, type, and consistency to meet acceptable nutritional values. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifier #58, #20. Facility Census 106.

Inspectors wroteBased on Record Review, Observations and Resident Interviews, the facility failed to hold or serve food at acceptable/palatable temperatures. This failed practice had the potential to affect more than a limited number of residents. Facility census: 106.

Inspectors wroteBased on observation, record review, resident interview and staff interviews the facility failed to ensure residents' food likes and dislikes were honored and food substitutes of equal value were offered. Resident Identifiers: #25, #84, #79 and #68 Facility Census: #106 Findings Include: a) Resident #25 On 02/16/25 at 12:15 PM it was observed that Resident #25 had broccoli florets on the lunch tray. The meal ticket stated Dislikes/DO NOT SERVE as Broccoli Florets. It was confirmed with the Director of Activities #41 on 02/16/25 at 12:17 PM that Resident #25 should not have received broccoli, she agreed. On 02/18/25 at the lunch meal Resident #25 was served broccoli again as substitute for roasted Brussels sprouts. It was confirmed with Nurse in Training #108 that Resident #25 should not have received broccoli. [...]

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to provide ordered adaptive equipment to Residents #68 and 60 during meals. These were random opportunities for discovery. Resident identifiers: #68, #60. Facility census: 106.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store and label food, store utensils and ensure food preparation equipment was clean and sanitary in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility census:

Inspectors wroteBased on observation, record review and staff interview, the facility failed to properly dispose of garbage in accordance with professional standards for food service safety and to ensure garbage was not hanging out of the trash can and on the ground below. This failed practice had the potential to affect more than a limited number of residents. Facility Census:

Inspectors wroteBased on record review and resident and staff interview, the facility failed to maintain accurate records for three (3) of 43 residents. The record was inaccurate pertaining to blood pressures for Resident #52. There was discrepancies between orders and the care plan for Resident #457, and daily meal percentages for Resident #106. Facility census: 106.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to thoroughly investigate an allegation of abuse involving Resident #39. This was true for one (1) of nine (9) residents reviewed for abuse and neglect during the survey process. Resident identifier: 39. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure accurate Minimum Data Set assessments for two (2) of 43 residents in the long-term care survey sample. Resident identifiers: #8 and #44. Facility census: 106.

Inspectors wroteBased on record review, observation and staff interview the facility failed to develop/implement a person centered care plan to meet and/or address the residents medical, physical, mental, and psychosocial needs. This failed practice was found true for (2) two of 43 care plans reviewed during the Long-Term Care Survey Process. Resident identifiers: #22 and #68. Facility census: 106.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to revise the care plan for Resident #14 after the order for adaptive equipment during meals was not renewed. This was true for one (1) of 43 care plans reviewed during the survey process. Resident identifier: 14. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to conduct yearly evaluations on Nurse Aides (NA). This has the potential to affect more than a limited number of residents. Employee idenifier: Nurse Aide (NA) #4 Facility census: 106.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. An insulin pen had not been discarded 28 days after opening. This was a random opportunity for discovery during the facility task of medication storage and labeling. Resident identifier: #56. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to perform laboratory testing according to physician's orders for two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #8 and #95. Facility census: 106.

Inspectors wroteBased on observation and staff interview, The facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Facility census: 106.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the medical director/designee attended quarterly Quality Assessment and Assurance (QAA) meetings. This had the potential to affect all residents that resided at the facility. Facility census: 109.

Inspectors wroteBased on observation, staff interviews, and facility documents, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The failed practices were found in the areas of monitoring and prevention of Legionella, establish and implementing a surveillance program, donning appropriate Personal Protection Equipment (PPE) while providing care for residents placed in Enhanced Barrier Precautions, and using proper PPE when entering a Contact Isolation room. These failed practices had the potential to affect more than a limited number of residents who currently reside at the facility. Facility census 109.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents with orders for insulin received necessary treatment and services as per their physician orders. The facility failed to recheck blood sugar levels when they were above 400. This was true for one (2) of seven (7) residents reviewed. Resident identifiers: #18 and #503. Facility census: 109.

Inspectors wroteBased on resident interview, observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #47 expressed to the surveyor he smoked at the facility without staff supervision and kept his own cigarettes and lighter. An interview with the Resident's Licensed Practical Nurse (LPN) #37 confirmed the Resident had asked her earlier in the day to take him out to smoke. The LPN's only response was, you know you are not allowed to smoke. Twenty seven (27) additional residents were identified as lacking capacity and being able to ambulate/wander throughout the facility. [...]

Inspectors wroteBased on facility record review, observations and staff interview the facility failed to display the daily staff posting at an accessible height for residents to view. This practice had the potential to affect more than a limited number. Facility census: 109.

Inspectors wroteBased on observation and staff interview the facility failed to ensure all multiple use vials and/or pens of insulin were dated with the initial date they were opened. This was true for six (6) out of nine (9) vials and/or pens in the Medication cart on the A hall. Resident identifiers: #553, #50, #19, #1, #34, #70, and #97. Facility census 109.

Inspectors wroteBased on observation, staff interview and resident interview, the facility failed to ensure food items were served at the preferable temperature for the residents. This has the potential to affect more than a limited number of residents. Facility census: 109.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain properly stored and dated food. This had the potential to affect more than a limited number of residents. Census 109.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain proper garbage disposal. This had the potential to affect all residents residing at the facility. Census 109.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of the resident's medical record. This was true for one (1) of 26 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #30. Facility census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident representatives in a timely fashion when a residents experienced changes in condition, appointments were scheduled, x-rays were done, and new medications were ordered. This was true for two (2) of 25 residents reviewed in the Long-Term Care Survey Process. Resident Identifiers: #30 and #101. Facility Census: 109.

Inspectors wroteBased on resident interview, observation, and staff interview, the facility failed to ensure residents had a safe/functional/sanitary and comfortable environment. The call light did not work in room [ROOM NUMBER]. Slats were missing from window blinds for rooms [ROOM NUMBERS]. Resident #90's wheelchair was in disrepair as well as a night stand for Resident #504. Resident identifiers: #38, #98, #90, #504. Facility census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident with newly evident or a possible serious mental disorder. This was true for one (1) out of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #1. Facility census 109.

Inspectors wroteBased on resident interview, staff interviews, observation, and record review, the facility failed to revise a care plan, for one (1) of six (6) residents reviewed for the category of accidents , during the long term care survey. Resident identifier #47. Census 109. Findings Included: a) Resident #47 A resident interview was conducted on 06/26/23 at 11:53 AM. The resident stated he did not like the smoking situation at the facility. The resident admitted to going off the property to smoke. The resident also stated he knows he is not supposed to but he keeps his lighter and cigarettes in his murse, attached to his wheelchair. (He defined a murse as a man purse). A follow up interview with the resident on 06/26/23 at 1:00 PM, confirmed the resident had been smoking at the facility for a while. [...]

Inspectors wroteBased on observation and staff interview, staff failed to administer medications via percutaneous endoscopic gastrostomy (PEG) tube according to professional standards. Crushed medications and flushes were pushed into the PEG tube and not administered by gravity flow. This was a random opportunity for discovery which has the potential to affect only a limited number of residents. Resident identifier: #22. Facility census: 109.

Inspectors wroteBased on resident interview, observation, and staff interview, the facility failed to ensure two (2) of 109 Residents had a functioning call system to alert staff when assistance was needed. Resident identifiers: #98 and #38. Facility census: 109.