Mountain View Health & Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services, in that: The facility, which was licensed for 187 beds, failed to employ a qualified social worker on a full-time basis since 05/30/2026. This failure put facility residents at risk of not having their psychosocial or discharge planning needs met.

Inspectors wroteBased on interviews, and record review, the facility failed to conduct assessments that accurately reflected the resident's status for 1 of 4 residents (Residents #2) reviewed for resident assessments. The facility failed to ensure Resident #2's Annual MDS Assessment accurately reflected resident's behaviors exhibited ongoing basis when daily care was provided. The failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure behaviors were addressed in Resident #2's Care Plan. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #4) reviewed for quality of care in that:The facility failed to ensure CNA I and CNA J correctly applied the gait belt to transfer Resident #4 from the wheelchair to the bed. The failure could put residents at risk of accidents and serious injuries which could result in a reduced quality of life.

Inspectors wroteBased on observation, interview and Record review, the facility failed to ensure food was maintained and served in a palatable manner for 1 of 1 Kitchen observations reviewed for food temperatures. The facility failed to store thawed waffles under appropriate cold holding temperatures on 04/09/2026. This failure could affect food quality, safety and resident consumption.

Inspectors wroteBased on observations, interviews, and record review the facility failed to distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage.-The facility failed to ensure dietary staff followed proper food safety practices for hand hygiene after contamination on 03/24/2026. This failure had the potential to place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention program designed to provide safe, sanitary, and prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #8 and Resident #77) reviewed for transmission-based precautions.- The facility failed on 03/24/2026 to ensure an unattended IV saline syringe flush was not left on Resident #77' nightstand.- The facility failed on 03/24/2026 and 03/25/2026 to ensure Resident #8's Eternal Feeding Syringe was not uncovered on his nightstand or in his dresser. The failures placed residents at risk for developing a preventable infection during patient care. Findings Included:Findings Included: 1. Resident #8 Record review of Resident #8 face sheet dated 03/26/2026 revealed an [AGE] year-old male with an admission date on 08/11/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 3 of 28 residents (Residents #13, #56 and #87) reviewed for call lights. The facility failed to ensure resident call lights were within reach for Residents #13, #56 and #87 on 03/24/2026. This failure placed residents at risk of having their needs unmet when they were unable to contact staff.

Inspectors wroteased on interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 8 residents reviewed for MDS assessments. (Resident #63).-The facility did not accurately code Resident #63's MDSs for a pressure ulcer on the Sacrum that had resolved 11/30/2026. This failure could place the census of 133 residents at risk of not receiving adequate care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and PASRR evaluation report into the resident's assessment, care planning, and transitions of care for 1 of 7 (Resident #149) residents reviewed for PASRR services.-The facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting from 12/18/2025This failure placed the PASRR residents at risk from not receiving services identified by the IDT in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 resident (Residents #63) of 6 residents reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident #63 by showing a resolved wound as active. These failures could affect residents and put them at risk for not receiving care and services to meet their needs. Record review of Resident #63's admission Record dated 03/26/2026 revealed a [AGE] year-old female with admission date 11/07/2025. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents ( Resident #40) reviewed for ADL care.- The facility failed on 3/24/2026 to ensure Resident #40's fingernails were trimmedThis failure could place residents who required assistance with ADLs at risk for unmet care needs.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that resident receive proper treatment and care to maintain mobility and good foot health for 1 of 1 residents (Resident #119) reviewed for foot care. The facility failed on 3/24/2026 to ensure Resident #119's toenails were trimmedThis failure could place residents who required specialized foot care at risk for unmet care needs, infections, and health complications. Resident #119Record review of Resident #119's face sheet dated 3/26/2026 revealed a [AGE] year-old female with an original admission date on 04/01/2020 and a readmission date on 11/13/2023. Record review of Resident #119's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the resident's environment remained as free of accident hazards as was possible for 1 of 7 residents (Resident #123) reviewed for Accidents-the facility failed from 03/24/2026 to 03/26/2026 to ensure Resident #123 did not have a mini fridge resting on top of a wobbly table. This failure placed the resident at risk for injury from a foreseeable and avoidable hazard.

Inspectors wroteBased on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 4 medication carts (500 Hall nurse cart) reviewed for cleanliness. The facility failed to ensure bottles of liquid medication (milk of magnesia and lactulose), stored in medication cart on the 500 hall did not have dried drippings on the sides of the bottles. This failure could affect residents by placing them at risk of cross contamination.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 of 8 (Residents #12) residents reviewed for special eating equipment.-The facility failed to provide Resident #12's physician ordered cup with lid for drinking fluids on 03/24/2026, 03/25/2026 and 03/26/2026. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care for 6 (Residents #1, #2, #3, #7, #8 and #9) of 14 residents reviewed for care plans and assessments. -The facility failed to conduct a safety smoking assessment for Residents 1, 2, 3 and 8. -The facility failed to update Residents 1, 2, 3 and 8's care plans to include they smoked and were able to safely smoke. These failures could place residents at risk of not having care needs met regarding smoking supervision which could result in health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for 7 (Residents #1, #2, #3, #5, #7, #8 and #9) of 14 residents reviewed for quality of care. The facility failed on 02/12/2026 to ensure CNA C communicated to the Charge Nurse or DON of Resident #5's fall. This failure could place residents at risk of not having care needs met, which could result in health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents for 5 (Resident #1, Resident #2, , Resident #8, Resident #7 and Resident #9) of 14 residents reviewed for smoking safety. -The facility failed to conduct a safe smoking assessment for Resident #1.-The facility failed to update Resident #2's care plan for smoking.-The facility failed to ensure Resident #7 had cigarettes in his room. -The facility failed to ensure Resident #8 had a safe smoking assessment and a care plan for smoking.-The facility failed to ensure Resident #9 had a cigarette lighter in his room.-The facility failed to assess and supervise residents who smoked.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to make choices regarding aspects of his daily life, including beverage preference, for 1 of 6 residents reviewed for resident rights (Resident #6). The facility failed to honor Resident #6's wishes by not providing him with the beverage of his choice.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to implement Resident #1's comprehensive person-centered care plan for repositioning assistance by two staff members. On 11/11/25, CNA A repositioned the resident alone. During the process, the resident rolled off the bed and struck his head on the suctioning machine suffering from a brain bleed, sustaining a 2 cm laceration above the right eyebrow, orbital fracture, and sinus fracture. The noncompliance was identified as PNC. The IJ began on 11/11/25 and ended 11/11/25. The facility had corrected the noncompliance before the investigation began. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 7 residents reviewed for accidents and supervision. Resident #1 required two-person assistance for peri care and repositioning. On 11/11/25, CNA A repositioned the resident alone. During the process, the resident rolled off the bed and struck his head on the suctioning machine, causing for him to suffer a brain bleed, sustaining a 2 cm laceration above the right eyebrow, orbital fracture, and sinus fracture. The noncompliance was identified as PNC. The IJ began on 11/11/25 and ended 11/11/25. The facility had corrected the noncompliance before the survey began. These failures placed residents at risk of injuries, hospitalization, and death.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infections for 1 of 2 (Resident #2) residents reviewed for quality of care. The facility failed on 11/17/2025 to ensure the pressure ulcer on Resident #2's right glute was covered with a dressing as ordered. This deficient practice could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds.

Inspectors wroteBased on observation, interview, and record review 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 for 1 (Resident #2) of 2 residents reviewed for infection prevention and control. LVN J and CNA K failed on 11/17/25 to use PPE (special equipment that protects the wearer's body from infection) during wound care for Resident #2 as the resident was on EBP.LVN J and CNA K failed on 11/17/25 to wash their hands prior to having contact with the resident. These failures could place residents at risk of infections, cross contamination, secondary infections, tissue breakdown, and communicable diseases.

Inspectors wroteBased on observation, interview and record review 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 for 1 of 10 residents (Resident #4) reviewed for infection prevention and control. 1. The facility failed to implement precautions and interventions after Resident #4 was sent out to the hospital for isolation due to a positive AFB (a type of bacteria causing tuberculosis) to ensure there was no spread of infection or disease. These failures could place residents at risk for infections, secondary infections, communicable diseases due to improper care practices.

Inspectors wroteBased on interview and record review the facility failed to ensure a notice of rights and services were provided to residents prior to or upon admission and during the resident's stay and ensure receipt of such information, and amendments to it were acknowledged in writing for 1 of 3 Residents (Resident #1) reviewed for Resident Rights. The facility failed to provide Resident #1 with an admission packet and notice of Resident Rights upon admission. This deficient practice could place residents at risk of not being aware of their rights, responsibilities, and the facility's policies.

Inspectors wroteBased on interview and record review the facility failed to establish and implement admission policies for 1 of 3 residents (Resident#1) reviewed for admission. The facility failed to ensure Resident #1 and/or Resident #1's family members completed a signed admission agreement upon admission to the facility on [DATE]. This deficient practice could place residents at risk of not being made aware of their rights, the facility characteristics and services provided by the facility or policies of the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident and the resident's representative(s) of the a transfer or discharge were notified and the reasons for the move were in writing and in a language and manner they understood and a copy of the notice was sent to the a representative of the Office of the State Long-Term Ombudsman and the notice of transfer or discharge required was made by the facility at least 30 days before the resident was transferred or discharged for 1 of 3 residents (Resident #1) reviewed for discharges. 1. The facility failed to provide a 30-day written discharge notice to Resident #1 and/or Resident #1's Responsible Party when he was discharged on 08/10/25. 2. The facility failed to provide the Ombudsman with a notification of Resident #1's discharge on [DATE]. [...]

Inspectors wroteBased on observation interview, and record review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #5) of 3 residents reviewed for foley catheter. The facility failed ensure Resident #5's indwelling catheter bag was kept from touching the floor. This deficient practice could place residents with indwelling catheters at risk of disease and infection.

Inspectors wroteBased on interview and record review the facility failed provide each resident with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 3 residents (Resident #1) reviewed for behavioral health services. The facility failed to use the on-call psychiatric service on 08/09/25 to refer Resident #1 for psychiatric services/evaluation after showing increasing signs of behaviors, verbalized suicidal ideation, physical aggression, and agitation on 08/09/25. This deficient practice could place residents at risk of not maintaining a sense of well-being that could affect their health.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to implement policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety for 4 (Resident #1, Resident #2, Resident #3 and Resident #4) out of 10 residents reviewed for smoking. The facility failed to implement their smoking policy by allowing Resident #1, #2, #3, and #4, to smoke indoors in an undesignated smoking area on 08/07/25. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 9 residents (Residents #1) reviewed for neglect. The facility failed to coordinate care and services with the hospice provider to ensure the written plans of care included both the most recent hospice plan of care and a description of the services furnished by the nursing facility to prevent neglect. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base). An Immediate Jeopardy (IJ) situation was identified on 05/02/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent for 1 of 9 residents (Residents #1) reviewed for accidents. The facility failed to ensure the Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base). An Immediate Jeopardy (IJ) situation was identified on 05/02/25. While the IJ was removed on 05/05/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure coordination of care to ensure hospice services were provided according to the services the LTC facility provided based on resident's care plan for 1 of 9 residents (Residents #1) reviewed for hospice services. The facility failed to coordinate with hospice interdiciplinary team to coordinate care to the resident provided by facility staff and hospice staff for those residents receiving these services. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base) resulting in placement in the hospital ICU. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent neglect of residents, and failed to establish policies and procedures to investigate such allegation for 1 of 9 residents (Residents #1) reviewed for neglect. The facility failed to ensure the Administrator followed the facility's abuse/neglect policy, by not completing an investigation and reporting an allegation of neglect involving Resident #1. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment are throughly investigated to prevent further potential while the investigation is in progress for 1 of 9 residents (Residents #1) reviewed for neglect. The facility failed to ensure the Administrator followed the facility's abuse/neglect policy, by not completing an investigation and reporting an allegation of neglect involving Resident #1. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 7 (Resident #2) residents reviewed for abuse. The facility failed to immediately suspend LVN A after Resident #2 reported that one nurse matched the description provided by the Resident #2. This failure could place residents at risk of abuse by not immediately following the facility abuse policy and procedure manual of taking the necessary measures to protect residents from harm during and following an abuse, neglect, exploitation, mistreatment of resident's investigation.

Inspectors wroteBased on interview and record review the facility failed to ensure alleged violations involving abuse, neglect, exploitation, or mistreatment, including misappropriation were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (DON & ADON) of 2 staff reviewed for reporting. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 residents (Resident #49 and #68) of 22 residents reviewed for call light placement. The facility failed to ensure call light was placed within reach for Resident #49 and Resident #68 This failure places residents at risk of having needs unmet when they are unable to contact staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for 2 of 22 (Resident #63 and #94) residents reviewed for telephone use. The facility failed to provide a place for Resident #63 and Resident #94 to make telephone calls without being overhead. This failure could place residents at risk of conversations being overheard and privacy rights not being respected.

Inspectors wroteResident #63 Privacy 12/18/24 09:55 AM Record Review of the facility's P&P 5. The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. This includes the right to retain and use a cellular phone at the resident’s own expense.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Dietary Aide G used a pitcher that had been placed in an uncleaned black cart and proceeded to refill it with tea by using the pitcher to scoop tea from the tea container before pouring it into cups. This failure could place residents who received drinks from the kitchen at risk for food borne illness.

Inspectors wroteFACILITY Infection Control Resident # 9 [NAME] TB 2 Step Mantoux Skin Test - Step 2 05/14/2021 Negative (0 mm) System. SARS-COV-2 (COVID-19) - Dose 1 208 06/01/2022 Complete System RSV 306 12/19/2023 Complete System PPSV23 33 12/05/2023 Complete System Fluzone High-Dose 135 Not Eligible System FLUAD QUADRIVALENT 205 09/30/2024 Complete System Covid-19 Spikevax (Historical Use Only) 207 01/10/2024 Complete System Resident # 22 [NAME]: [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure they followed professional standards of practice in accordance with physician orders and facility policy for care of midline for 1 (Residents #27) of 4 residents reviewed for parenteral and intravenous care. The facility failed to change Resident #27's PICC line dressing as ordered. This failure placed the residents at risk of complications with their midlines needed for infusion therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #27) reviewed for pharmacy services. Resident #27 had an over the counter Selenium 200 mcg bottle and an over the counter Aspirin 81 mg bottle at his bedside. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 (treatment cart) reviewed for medication storage and security. The facility failed to ensure LVN A secured the facility's only treatment cart when it was left unattended. This failure could place residents at risk for drug diversion or accidental ingestion.

Inspectors wroteBased on interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 1 of 8 (Resident #27) residents reviewed for accurate medical records. RN C documented he had changed Resident #27's PICC line when the task had not completed. This failure could place residents at risk for of having incomplete or inaccurate records and inadequate care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #5) reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #5 who had two different transfers (two-person transfer with mechanical lift and transfer 1 person transfer) implemented at the same time. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on interviews and record review the facility failed to ensure that the residents environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #5) of 5 residents reviewed for accidents. The facility failed to ensure that Resident #5 who was a two-person transfer was transferred as a two-person transfer with mechanical lift instead of a one-person transfer . CNA C failed to report Resident #5 had a fall resulting in pain to nursing when Resident #5 was guided down to the floor hitting his right knee and having his left leg extended. This failure could place residents at risk of falls or injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 5 residents (Resident #16) reviewed for freedom from physical restraints. -The facility failed to obtain consent, physician's order, and care plan for Resident #16's full bed rails in which the resident movements were restricted and there was no documentation the restraints were required to treat her medical symptoms. This failure could put residents at risk of unnecessary restriction of their freedom of movement (any change in place or position for the body or any part of the body that the person is physically able to control).

Inspectors wroteBased on observation, interview, and record review the facility failed to 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 for 1 of 7 (Resident #7) residents reviewed for Covid-19. The facility failed to ensure Resident #7's, who was isolated for Covid-19, door was kept closed. This failure could put residents at risk of exposure to Covid-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #16, and Resident #17) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Residents #16's and #17's catheter leg strap was in place to secure the catheter. 2. The facility failed to ensure Resident #17's drainage bag was off the floor. This failure could place residents with foley catheters at risk of catheter pulling causing pain and/or infection and risk for infection due to improper care practices and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 disease and infection for 1 resident (Residents #9) of 10 residents reviewed for infection control. - The facility failed to ensure staff followed infection control practices of washing hands after glove use during medication administration. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #1) of 4 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 had neurological checks done for 3 unwitnessed falls of 5 unwitnssed falls experienced by Resident #1 (2 falls on 11/29/23 and 1 on 12/11/23). 2. The facility failed to ensure Resident #1 had weekly skin assessments done for 1 of 4 weeks and failed to identify Resident #1 had scars, marks, or scabs. These failures could affect residents by placing them at risk of potential medical complications related to changes in condition.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #1) of 5 residents reviewed for accuracy of the MDS assessment. Resident #1's quarterly MDS did not accurately reflect the residents' need for the use of a mechanical lift. This deficient practice could place residents at risk of inadequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1 who had two different transfers (two person transfer with mechanical lift and transfer 1-2 person as needed) implemented at the same time. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on interviews and record review the facility failed to ensure that the residents environment remained free of accidents and hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to ensure that Resident #1 who was a two-person transfer was transferred as a two person transfer instead of a one-person transfer. This failure could place residents at risk of falls or injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #2) of 5 residents observed for oxygen management. 1. Resident #2 was receiving oxygen, as needed, without a physician's orders. 2. Resident #2's oxygen tank was empty as it was marked red. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to 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 disease and infection for 1 of 5 residents (Resident #2) reviewed for infection control. Resident #2's nasal cannula was hanging on the back of her wheelchair unbagged. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purpose of discipline or convenience, and not required to treat the resident ' s medical symptoms for 6 (Resident #63, Resident #86, Resident #21 Resident #183, Resident #20, and Resident #53) of 6 reviewed for physical restraints in that: The facility failed to obtain consent for Resident #63, Resident #86, or Resident #20 to have bolsters placed on the bed. The facility failed to obtain a physician ' s order with medical indications for bolsters to be placed on the bed for Resident #63, Resident #20 or Resident #21. The facility failed to assess Resident #86 for the need for bolsters. The facility failed to obtain physician ' s order for Resident #183 to have bolsters. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident ' s status for 7 (Resident #20, #31, #63, #86,#21 and #183) of 39 residents reviewed for accuracy of MDS assessments. -The facility failed to ensure Resident #20, Resident #63, Resident #86, Resident #21 ' s and Resident #183 ' s MDS assessments documented the use of restraints. - The facility failed to ensure Resident #31 ' s Quarterly MDS assessment documented her significant weight loss. - The facility failed to ensure Resident #183 ' s MDS assessment adequately documented the resident ' s impaired vision. This failure could put residents at increased risk of not having their treatment needs identified and met.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 5 (Resident #21, #63, #86, #124, and #183) of 39 residents reviewed for comprehensive care plans The facility failed to ensure the care plan for Resident #21 addressed his use of psychotropic medications. The facility failed to ensure the care plan for Resident #63 addressed the use of bolsters. The facility failed to ensure the care plan for Resident #86 addressed the re-assessment for use of bolsters. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents maintained their usual body weight for 2 (Resident #31 and #183) of 12 residents reviewed for maintenance of usual body weight. -The facility failed to ensure that Resident #31 did not have unplanned weight loss of less than 5% in a month, or less than 10% in a 6-month period. -The facility failed to ensure that Resident #183 was administered bolus feeding when less than 50% of a meal was eaten. This failure could result in residents experiencing unplanned weight loss, decreased energy and increased risk of loss of skin integrity.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident # and Resident #245) of 3 residents observed for oxygen management. - Resident #86 did not have extra tracheostomy cannula at bedside. - Resident # 245 was receiving oxygen therapy inappropriately and not according to facility policy. This failure could cause a decline in health in residents receiving oxygen therapy if the necessary equipment was not available and if oxygen therapy was not administered correctly.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food that was palatable and served at an appetizing temperature 2 of 2 meals reviewed for palatability and temperature. -The facility failed to ensure food was served at appropriate temperature. -The facility failed to ensure the puree food served has appetizing flavor. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standers for food services for 1 of 2 kitchen reviewed for dietary sanitation in that: The facility failed to ensure Kitchen Aide O was wearing hairnet while in the kitchen. The facility failed to dispose of expired food in the refrigerator. The facility failed to ensure milk stored in refrigerator was labeled. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review that facility failed to extend to the resident representative ' s the right to make decisions on behalf of the resident for 1 of 10 (Resident #20) residents reviewed for resident rights in that: The facility failed to inform Resident #20 ' s RP before cutting her hair. This failure could place residents at risk of receiving services without consent.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #183) of 39 residents reviewed for accommodation of needs. The facility failed to ensure that Resident #183's call light was within reach and could be used by her. This failure could place residents at risk of not being able to call staff when assistance was needed.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (300 Hall) of 4 medication carts reviewed for medication storage. -300 Hall medication cart had expired medication. This deficient practice could cause a decline in health in residents if expired medication was to be given.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's responsible party has the right to exercise the resident's rights for one (Resident #4) of seven residents reviewed for resident rights. The facility failed to ensure Resident #4's RP was involved in the decision making to discharge resident from facility. This failure could place residents at risk of not having their preferred responsible party represent them in a medical and care decisions.

Inspectors wroteBased on interview, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 7 (Resident #4) residents reviewed for accuracy. The facility failed to document Resident #4's alleged smoking in room incident on 08/23/2023 and having cigarettes in room on 08/24/2023.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for three of thirty-eight days reviewed for nurse staffing information. The facility failed to post the required staffing information for September 09/06/2023. The facility failed to have staffing information for 09/04/2023 and 09/05/2023. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.