Mountain View Health and Rehabilitation

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was treated with respect and dignity when staff members discussed another resident's preferences while performing a resident's wound care for 1 of 26 sampled residents (Resident #2). This deficient practice had the potential to result in a resident experiencing feelings of diminished self-worth due to staff members engaging in a conversation about another resident, which excluded Resident #2, while providing wound care to the resident.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure a resident was free from misappropriation of personal property when the volume of liquid Morphine Sulfate remaining in a medication bottle did not match the facility's narcotic count in a narcotic logbook for 1 of 5 unsampled residents' records reviewed for compliance with medication storage and administration (Resident #24). This deficient practice had the potential to result in the resident not having an adequate amount of Morphine available to treat the resident's pain.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure the facility's policies related to misappropriation of resident property, abuse, and neglect were implemented timely for an allegation of misappropriation of resident property and neglect. This deficient practice resulted in delayed removal of an alleged perpetrator from resident care and access to residents' medications, placing all residents at risk for misappropriation of property and neglect.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 26 sampled residents (Resident #74). This deficient practice had the potential to deprive the resident of a person-centered care plan and the associated interventions relative to their current health management needs.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a comprehensive care plan was developed related to a COVID-19 infection for 1 of 26 sampled residents (Resident #108), and 2) a resident's care plan for the care of the resident's pressure ulcer was implemented for 1 of 26 sampled residents (Resident #2). These deficient practices had the potential to result in staff being unaware of resident needs and resident needs going unmet and to result in a resident not receiving the care necessary to prevent the worsening of a chronic wound.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was provided pressure ulcer care as ordered by the resident's provider for 1 of 26 sampled residents (Resident #2). This deficient practice had the potential to result in a resident's pressure ulcer worsening or developing an avoidable infection.

Inspectors wroteBased on observation, clinical record review, interview and document review, the facility failed to ensure staff provided adequate supervision for 1 of 26 sampled residents (Resident #87) when staff failed to verify all residents were present after discovering an open window on a secured memory care unit. This deficient practice resulted in delayed identification of a resident elopement and delayed implementation of the facility's elopement response procedures, with the potential to result in psychosocial and physical harm to the resident including injury or death.

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure 1 of 20 sampled employees had the specific competencies and skill sets necessary to care for residents' needs (Employee #15). This deficient practice had the potential to result in physical and psychosocial harm to the residents in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1) medications were secured in a locked medication cart and inaccessible to residents, staff and visitors when a Registered Nurse (RN) left two bottles of medication on top of a medication cart when the cart was not within sight of the RN and 2) outdated medications were removed from 1 of 4 medication carts inspected for medication storage. This deficient practice had the potential for residents, visitors, and unauthorized staff to have access to medications and outdated medications with diminished efficacy to be administered to residents.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to complete a Treatment Administration Record (TAR) for the monitoring of side effects of an anticoagulant medication, the monitoring of a Foley catheter, and the monitoring of enhanced barrier precautions, for 1 of 26 sampled residents (Resident #14). This deficient practice had the potential to inaccurately reflect the prescribed monitoring of care and the associated interventions relative to the resident's current health management needs.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure 1) staff wore appropriate Personal Protective Equipment (PPE) when entering the rooms of 2 of 14 coronavirus (COVID-19) positive residents (Residents #108 and #58) and 2) enhanced barrier precautions (EBP) were appropriately implemented and a staff member performed hand hygiene appropriately when performing wound care for 1 of 26 sampled residents (Resident #2). The deficient practice had the potential to spread infectious illnesses to vulnerable residents in the facility and result in a resident developing an infection from a staff member's lack of hand hygiene or failure to follow appropriate EBP.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a staff member received screening and education on the Sars Coronavirus 2019 (COVID-19) vaccine for 1 of 1 staff sampled for COVID-19 vaccine review. This deficient practice had the potential to result in a staff member not having the opportunity to receive the vaccine or education on the risks and benefits of the vaccine.

Inspectors wroteBased on personnel record review, interview, and document review, the facility failed to ensure initial behavioral health care training, related to dementia, was completed timely for 2 of 20 sampled employees (Employee #9 and #10). This deficient practice had the potential to prevent residents with dementia care needs from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on clinical record review, document review, and interview, the facility failed to notify the on-call medical provider after a resident experienced a fall with injury, resulting in bruising to the forehead for 1 of 25 sampled residents (Resident #2). This deficient practice had the potential to result in delayed identification and treatment of serious complications, including intracranial bleeding, for a resident receiving anticoagulation therapy.

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure initial elder abuse prevention training was completed timely for 1 of 10 sampled employees (Employee #8). This deficient practice had the potential to place all residents at risk for abuse and neglect.

Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to ensure the safety of a resident with wandering behaviors from elopement from the facility for 1 of 16 sampled residents (Resident #13). The deficient practice had the potential for physical and psychosocial harm to the resident.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to protect residents from physical abuse for 2 of 28 sampled residents (Resident #72 and #104) from resident to resident abuse. Resident #104 obtained a facial fracture resulting in actual harm. Resident #72 obtained lacerations requiring eight staples resulting in actual harm.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1) a medication cart containing resident medications was secure, 2) an open multi-dose vial had the date opened and initials of the first person to use the vial written on it in 1 of 2 medication storage rooms reviewed and 3) outdated medications were removed from 3 of 3 medication carts reviewed and 1 of 2 medication storage rooms reviewed. The deficient practice could have facilitated unauthorized access to medications in the cart and had the potential for outdated/expired medications to be administered to residents.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 26 opportunities and 14 medication errors. The medication error rate was 53.85%.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure a resident's right to self determination was respected when the facility failed to inform a new Certified Nursing Assistant (CNA) of the resident's wishes not to be disturbed for care during the night. The CNA continued to attempt to turn the resident after the resident had asked the CNA to stop, resulting in bruising to the resident's thigh for 1 of 28 sampled residents (Resident #23).

Inspectors wroteBased on interview, clinical record review and document review, the facility failed to ensure a comfortable, homelike environment when staff were reported as being loud and disruptive to a resident's sleep during the night shift for 1 of 28 sampled residents (Resident #112).

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 28 sampled residents (Resident #27). This deficient practice had the potential to deprive the resident of a person-centered care plan relative to their current health management needs.

Inspectors wroteBased on interview, clinical record review and document review the facility failed to provide showers for 1 of 28 sampled residents (Resident #108). The deficient practice had the potential to negatively impact the resident's overall well-being.

Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to ensure 1) a resident's significant surgical wounds were evaluated weekly for 1 of 28 sampled residents (Resident #67), 2) a resident's change in condition was reported timely to a physician for 2 of 28 sampled residents (Resident #36 and #62) and 3) ensure a resident's blood sugar levels were checked according to a physician's order for 1 of 28 sampled residents (Resident #52). The deficient practices had the potential to result in 1) overlooked skin integrity decline, 2) a change in condition going unmonitored, placing residents at risk for infection to spread and for poor clinical outcomes, and 3) a resident experiencing hyperglycemia (elevated blood sugar) or hypoglycemia (low blood sugar) without adequate monitoring and intervention.

Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to ensure oxygen was administered according to a physician's order for 1 of 28 sampled residents (Resident #80). This deficient practice had the potential to cause worsening of the resident's diagnosed chronic obstructive pulmonary disease.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to identify triggers for a resident diagnosed with post-traumatic stress disorder (PTSD) for 1 of 28 sampled residents (Resident #52). This deficient practice placed the resident at risk for re-traumatization.

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure 1) resident information was not visible on an unattended computer screen, and 2) records were accurate for 1 of 28 sampled residents (Resident #62).

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure ordered Enhanced Barrier Precautions (EBP) were implemented for a resident with chronic pressure ulcers for 1 of 28 sampled residents (Resident #60). The deficient practice had the potential for spreading infectious illnesses to the vulnerable resident.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure 1 of 5 residents (Resident #392) reviewed for vaccinations, including influenza vaccines (Resident #392) was adminitstered the vaccine after the resident's guardian had consented for the vaccine to be administered. The deficient practice had the potential to place the resident at risk for not being protected against serious illness.

Inspectors wroteBased on observation, interview and document review, the facility failed to accurately document the amount of a controlled substance in 2 of 2 sampled controlled substance logs and failed to ensure the discrepancies were reported to the Director of Nursing (DON).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure staffing in the 300 hall memory care was sufficient to ensure timely administration of medications resulting in the failure to ensure a medication error rate of less than 5 percent (%) and the facility did not experience excessively low weekend staffing.

Inspectors wroteBased on observation, interview, clinical record review, and document review the facility failed to ensure medication was administered with an error rate of less than 5 percent (%). There were 25 opportunities and 14 medication errors. The medication error rate was 56.0 %.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to prevent resident to resident physical abuse for 1 of 12 Facility Reported Incidents (FRI) (Resident #5).

Inspectors wroteBased on interview, record review, and document review the facility failed to document an investigation of alleged abuse for 1 of 25 sampled residents (Resident #114).

Inspectors wroteBased on interview and record review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) for 1 of 25 sampled residents (Resident #114).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident requiring assistance with nail care had the need care planned and a resident's care planned interventions for chronic pain were implemented for 2 of 25 sampled residents (Resident #29 and #16).

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to offer a non-English speaking resident translation services as care planned for 1 of 25 sampled residents (Resident #97).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident requiring assistance with nail care was provided with care to prevent the resident's toe nails from becoming overgrown for 1 of 25 sampled residents (Resident #29).

Inspectors wroteBased on interview, personnel record review and document review, the facility failed to ensure Cardio-Pulmonary Resuscitation (CPR) with First Aid training was completed for 1 of 5 sampled Licensed Nurses (Employee #2).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a history of a pressure ulcer and determined to be at risk for the development of a pressure ulcer received wound care per physician and the facility policy for 2 of 25 sampled residents (Resident #64 and #54).

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure a bed was in the low position per physician's orders and followed after a resident was identified as a high risk for falls and had a history of actual falls, in an attempt to prevent future falls for 1 of 25 sampled residents (Resident #1).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure an attempt was made to schedule a timely follow up appointment with a Urologist for a resident with a urinary catheter for 1 of 25 sampled residents (Resident #113).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was medicated for pain prior to procedures as care planned for 1 of 25 sampled residents (Resident #16).

Inspectors wroteBased on observation, interview, clinical record review and document review the facility failed to ensure an informed consent was obtained prior to installation of grab bars for 1 of 25 sampled residents (Resident #69).

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to obtain informed consent prior to administration of a psychotropic medication, ensure psychotropic medications were ordered and administered to treat a specific, diagnosed condition for 1 of 25 sampled residents (Resident #54) and ensure a resident on a psychotropic medication had a gradual dose reduction (GDR) for 1 of 25 sampled residents (Resident #22).

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure a dental consult was scheduled for damaged dentures for 1 of 25 sampled residents (Resident #114).

Inspectors wroteBased on interview, observation, clinical record review, and document review, the facility failed to provide meals based on resident's allergies for 1 of 25 sampled residents (Resident #3).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure transmission-based precautions (TBP) were initiated and discontinued per facility policy and staff were able to explain the reason a resident was on TBP for 1 of 25 sampled residents (Resident #31).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the menu was followed or updated for a lunch service.