Mountain View Care Center

Inspectors wroteBased on resident and staff interviews, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need.

Inspectors wroteBased on observation, resident and staff interviews, the facility failed to ensure that meals were served at an appetizing temperature for one resident (#46). The deficient practice could lead to nutritional issues and affect residents' quality of life. Resident #46 was admitted on [DATE], with diagnoses that included encounter for other orthopedic aftercare and type two diabetes mellitus with foot ulcer. The review of the resident's admission Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) summary score of 15, which confirms that the resident is cognitively intact. Review of the resident's orders revealed that the resident had an active order, as of December 05, 2023, for a NAS (No added salt) diet, regular texture, regular/thin consistency. [...]

Inspectors wroteBased on review of records, observation, interviews, and review of facility policy and procedure, the facility failed to ensure one resident (#31) was not abused by another resident (#37). The deficient practice could lead to physical and psychosocial harm to residents. Regarding the altercation between Resident #31 and Resident # 37. Resident #31 (alleged victim) was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and Dementia without behavioral disturbance. A review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 01 which indicated the resident is cognitively impaired. [...]

Inspectors wroteBased on observations, clinical record review, interviews and policy and procedures, the facility failed to ensure one resident (#54) was free from chemical restraint, by failing to implement a provider's order for a gradual dose reduction of a psychotropic medication. The deficient practice could result in residents being administered psychotropic medications as chemical restraints and not to treat medical symptoms.

Inspectors wroteBased on clinical record reviews, facility documentation, staff interviews, policy and procedures, the facility failed to investigate, prevent, or correct an alleged violation of abuse for one resident #64. The allegation of verbal abuse was thoroughly investigated involving two residents (#64) and (#41). The deficient practice could result in abuse not being addressed and investigated.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure a referral for a PASARR (Pre-admission Screening and Resident Review) level II determination was obtained timely for one resident (#57). This deficient practice could result in residents not receiving the appropriate level of services.

Inspectors wroteThe facility failed to ensure appropriate infection control measures were implemented and followed for one resident (#56) with a feeding tube while administering tube feeding. The deficient practice could result in a spread of preventable illness to residents and staff.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#57) was free from abuse from a visitor, five residents (#116, #59, #126, #112, and #134) were free from abuse from another resident and prevent an injury of unknown origin for one resident (#118). The deficient practice could result in residents being abused.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure adequate supervision was provided to prevent resident from wandering into other resident's room for two residents (#57, #116); and, prevent one resident (#129) from elopement. The deficient practice could result avoidable harm to all residents due to lack of adequate supervision.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policies and procedures, the facility failed to complete a thorough investigation to rule out abuse regarding an injury of unknown origin for one resident (#118). The deficient practice could result in the injury of unknown origin not investigated and appropriate corrective actions not taken.

Inspectors wroteBased on clinical record review, resident interview, staff interviews, and review of facility policies, the facility failed to ensure that three residents (#65, #211 and #11) received adequate supervision to prevent medication accidents. The deficient practice could result in the resident sustaining medication accident-related injuries.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure a referral for a PASARR (Pre-admission Screening and Resident Review) level II determination was obtained timely for one resident (#58). This deficient practice could result in residents not receiving the appropriate level of services.

Inspectors wroteBased on review of facility documentation, staff interviews and review of policies and procedures, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure that food was stored in accordance with professional standards for food safety. This deficient practice could increase the risk of food [NAME] illnesses through lack of refrigeration.

Inspectors wroteBased on observations, clinical record reviews, staff interviews, and policy reviews, the facility failed to ensure that services regarding medications provided to two residents (#42 and #297) met professional standards of quality. The deficient practice could result in residents not receiving medications as ordered by the physician.

Inspectors wroteBased on resident and staff interviews, facility documentation, facility assessment, and policy review, the facility failed to ensure that there was sufficient nursing staff to meet the needs of the residents. The deficient practice could result in residents' needs not being met.

Inspectors wroteBased on observations, facility documents, staff interviews, and policy reviews, the facility failed to ensure refrigerator/freezer temperatures were consistently monitored and that kitchen equipment was cleaned according to food safety standards. The deficient practice could result in foodborne illness.

Inspectors wroteBased on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity was maintained for one sampled resident (#78). The deficient practice could result in residents not being treated in a dignified manner.

Inspectors wroteBased on observations, resident and staff interviews, review of the clinical record, and facility policy and procedure, the facility failed to ensure unsupervised medications were not left on one resident's (#306) bedside table who had not been assessed to safely self-administer medications. The sample size was 23. The deficient practice could result in unsafe medication administrations.

Inspectors wroteBased on clinical record review, staff interview, and policy and procedure, the facility failed to ensure that two residents (#17 and #70) with a diagnosis of a serious mental illness were referred to the appropriate State-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents with diagnoses of mental illness of intellectual disability.

Inspectors wroteBased on clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#95) was administered scheduled pain medication in accordance with the physician order. The sample size was 4. The deficient practice could result in residents' pain not being adequately controlled.

Inspectors wroteBased on observations, review of the clinical record, staff interviews, and policy and procedure, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two residents (#42 and #297). The medication error rate was 6.67%. The deficient practice could result in possible side effects/complications from receiving medications that are not administered as ordered.