Mountain View Center Genesis Healthcare

Inspectors wroteBased on interview and record review the facility failed to complete accurate resident assessments for 2 of 13 sampled residents (Residents #1 and #2).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure that expired medications were removed from 1 of 2 medication storage rooms observed and 1 of 4 medication carts observed. The facility also failed to ensure medication carts remained locked when unattended during an observation. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 6/4/26.

Inspectors wroteBased on observation and interview the facility failed to provide privacy during care for 1 of 32 sampled residents (Resident #93).

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 32 sampled residents (Resident #63 and Resident #11) were care planned for concerns related to hearing and communication and positioning.

Inspectors wroteBased on interview and record review the facility failed to revise and implement a person-centered care plan for 1 of 32 sampled residents (Resident #48). The care plan was not revised and implemented to address Resident 48's escalating pattern of aggressive verbal and physical behavior.

Inspectors wroteBased on the interview and record review, the facility failed to implement safe mechanical lift procedures to prevent an avoidable accident for 1 of 5 sampled residents (Resident #1). The facility did not ensure that staff operating the mechanical lift were competent in the task per the facility policy. During transfer, Resident #1 sustained multiple skin tears and fractures to their body, including a fracture of the right femur (thigh bone) and a fracture to the left humerus (upper arm bone). This is a repeat violation previously cited in a partial survey dated 9/9/25.

Inspectors wroteBased on the interview and record review, the facility failed to ensure that 1 of 3 sampled Licensed Nursing Assistants possessed the specific competencies necessary to meet residents' needs, as identified through resident assessments and the plan of care. The facility did not ensure that staff operating the mechanical lift were competent in the task per the facility policy, which led to a resident sustaining multiple fractures and skin tears (Resident #1). This has the potential to affect all residents of the facility.

Inspectors wroteBased on interview and record review the facility failed to implement interventions to ensure residents were free of accidents for 1 of 3 residents (Resident #1). As a result, a resident suffered a fall which required hospitalization related to a fractured hip and pain management.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident medications were securely stored and expired medications and treatment materials were removed from possible use on all 4 resident units.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety.

Inspectors wroteBased on interview and record review, the facility failed to protect 2 of 4 of the applicable sample (Residents #34 and # 48) from coercion and reprisal by the facility, as evidenced by reprimanding residents for discussing concerns about the care they received with the State Agency.

Inspectors wroteBased on observations, interview, and record review, the facility failed to promote a homelike comfortable environment by not maintaining the room temperature for 1 of 27 sampled residents (Resident #2).

Inspectors wroteBased on interviews and record review, the facility failed to protect one resident (Resident #281) of 10 sampled residents from abuse.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment for 1 of 4 units (Unit D) resulting in all residents on the unit being subjected to continuous loud alarms throughout the day.

Inspectors wroteBased on observations, interviews and record review the facility failed to develop a person-centered comprehensive care plan for 3 of 36 residents sampled (Resident #72, #3, and #83).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good hygiene as evidenced by excessively long fingernails, long thick toe nails, not providing showers, shaving, and range of motion exercises, for 4 of 36 sampled residents (Resident #102, #40, #83, and #3).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the activities program meets the needs of each resident for 5 of 9 Sampled Residents (Residents #91, #19, #15, #95, and #72).

Inspectors wroteBased on observation and resident and staff interview, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs impacting 2 of 4 units (Units Dogwood and Cherry Tree).

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who use psychotropic drugs are accurately monitored for behaviors and/or side effects for 3 of 6 sampled residents (Residents #15, #10, and #98).

Inspectors wroteBased on observation and interview the facility failed to serve food that is palatable and at an appetizing temperature to 3 of 36 sampled residents (Resident # 99, #11 and #12)

Inspectors wroteBased on observation and interview the facility failed to ensure that refrigerated food temperatures were maintained at a safe level (Below 41 degrees) in the unit refrigerator in the Cherry Tree Country Kitchen.

Inspectors wroteBased on observation and interview the facility failed to ensure that 2 of 36 sampled residents were treated with dignity and respect, in relation to staff to resident interaction (Resident #66) and not providing assistance with meals and nutrition while other residents seated at the same table were served and eating their meal (Resident #99).

Inspectors wroteBased on interview and record, the facility failed to ensure that an alleged incident of a resident-to-resident altercation, which resulted in potential verbal abuse, was reported to the State Survey Agency for 1 of 36 of the applicable sample (Resident#66) Findings Include: Per record review, a nursing progress note reveals an entry dated March 31, 2024, This writer observed patient demonstrating verbal and aggressive behavior towards roommate due to frustration of time spent in the bathroom and patients inability to use facilities sooner causing incontinence. Patient attempted to throw self out of bed while screaming [I'm gonna beat [him/her!]! and other obscenities were yelled. This writer assisted RN with boosting patient back into bed to prevent fall/injury. [...]

Inspectors wroteBased on resident interview and record review, the facility failed to ensure that services provided meet professional standards as evidenced by failing to follow physicians' orders for 1 of 36 sampled residents (Resident #15).

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to provide safe and effective skin and wound care for 2 of 36 sampled residents (Resident #125 and #94) by failing to regularly and accurately perform and document weekly skin checks and non-pressure ulcer wound evaluations consistent with professional standards of practice and facility policy.

Inspectors wroteBased on interview and record review the facility failed to follow Pharmacy Recommendations related to monitoring of heartrate prior to administration of digoxin (a medication to slow the heartrate) for 1 Resident out of 6 sampled (Resident # 47).

Inspectors wroteBased on staff interview and record review, the facility failed to implement a system for controlling infections that follows accepted national standards as evidenced by not following accepted guidance for testing of staff to prevent the spread of COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident is refunded charges already paid for days the resident did not reside in the facility within 30 days of discharge for Resident #1.