Mountain View Health Services

Inspectors wroteBased on observation, interview, and record review it was determined, for 13 of 24 sampled residents, 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. Specifically, the facility failed to sanitize the blood glucose meters according to manufacturer requirements. This was determined to have resulted at an immediate jeopardy level. In addition, the facility had not updated their COVID-19 policy and procedures according to the latest guideline. Resident identifier: 1, 3, 6, 10, 11, 13, 14, 16, 22, 24, 35, 36 and 43. [...]

Inspectors wroteBased on interview and record review, it was determined for 2 of 24 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, residents' care plans did not include hospice services, did not address inappropriate sexual behaviors in a timely manner, and were not updated with new interventions after falls. Resident identifiers: 6 and 25.

Inspectors wroteBased on interview and record review, it was determined that the facility did not ensure that any individual working in the facility as a nurse aide for more than 4 months on a full time basis had completed a training and competency evaluation program approved by the State. Specifically, three nurse aides were found to have worked at the facility for more than 4 months without completing a training and competency evaluation program approved by the state. Staff identifiers: 1, 2 and 3. Findings Include: On 1/8/26, five employee files were reviewed. The files of staff members 1, 2, and 3 indicated that those three staff members had been working at the facility for more than 4 months without completing a state-approved nurse aide training and competency evaluation program. On 1/8/26, an interview was conducted with the Administrator. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their written policies and procedures for feedback, data collection systems, monitoring to develop and implement appropriate plans of action to correct identified deficiencies. Specifically, there were repeat deficiencies and infection control was not identified during the Quality Assurance and Performance improvement (QAPI). Resident identifier: 3.

Inspectors wroteBased on interview and record review, for 5 of 5 sampled residents and 5 out of 5 sampled staff members, the facility did not develop and implement policies and procedures to ensure each resident and staff member were offered the COVID-19 vaccine unless the immunization was medically contraindicated or the resident or staff member had already been immunized. In addition, residents and staff were not educated regarding the benefits and risks and potential side effects of the vaccine prior to being offered. The resident's medical record and staff records did not include documentation education was provided regarding benefits and potential risk associated with the COVID-19 vaccine or if the residents refused or if the vaccine was medically contraindicated. Specifically, there was no documentation that residents and staff were educated and offered the COVID-19 vaccine. Resident identifiers: [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 24 sampled residents, the facility did not provide supervision to prevent accidents. Specifically, a resident sustained falls with no interventions developed and interventions were not implemented per the care plan. Resident 6.

Inspectors wroteBased on interview and record review, it was determined for 1 of 24 sampled residents, the facility did not obtain laboratory services to meet the needs of its residents. Specifically, one resident did not receive laboratory (lab) services for A1C (glycohemoglobin) and lipid panel as ordered. Resident identifiers: 25.

Inspectors wroteBased on interview and record review, it was determined for 2 of 24 sampled residents that the facility did not file in the resident's clinical record laboratory reports. Specifically, residents' laboratory (lab) results were not filed in their medical record. Resident identifiers: 25 and 43.

Inspectors wroteBased on interview and record review, it was determined for 1 of 24 sampled residents, the facility did not obtain the required information from hospice representatives and the facility did not communicate with the hospice representatives to coordinate hospice care. Specifically, the facility did not obtain the most recent hospice plan of care and the hospice election form for one resident. Additionally, that resident's plan of care did not include both the most recent hospice plan of care and a description of the services furnished by the Long Term Care facility. Resident identifiers: 25. Findings Included:1. Resident 25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizophrenia, obsessive-compulsive disorder, dementia, and adult failure to thrive. Resident 25's medical record was reviewed on 1/5/26 through 1/8/26. [...]

Inspectors wroteBased on observation, interview and record review the facility did not post nursing staff information each day for public access. Specifically, there was no nurse staff positing from 1/5/26 through 1/7/26.

Inspectors wroteBased on interview and record review, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. Specifically, for 1 out of 3 sampled residents, a resident was not readmitted after being transferred to the hospital. Resident identifier: 1.

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 of 30 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, ongoing monitoring for changes in condition were not provided after one resident experienced ongoing emesis and abdmoninal pain, and a second resident had a deep vein thrombosis. The findings for resident 46 were determined to have resulted in immediate jeopardy for resident 46. Resident identifiers: 46 and 298. [...]

Inspectors wrote2. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and anxiety disorder. Resident 298's medical record was reviewed on 8/7/24. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would suggest intact cognition. A review of resident 298's paper medical chart revealed an order dated 6/10/24, for a right lower extremity ultrasound to rule out a DVT [deep vein thrombosis]. A review of resident 298's progress notes revealed: a. [...]

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that policies were established and implemented to ensure that identified quality deficiencies were corrected. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents and the resident environment did not remain as free of accident hazards as was possible. Specifically, for 1 out of 30 sampled residents, a resident was not provided adequate supervision and interventions to reduce hazards and risks that resulted in an acute complete femoral neck fracture with partial displacement. Resident identifiers: 298.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, for 1 out of 30 sampled residents, a resident was not provided their ordered nutritional supplement shake and the resident had weight loss. Resident identifier: 298.

Inspectors wroteBased on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 30 sampled residents, a resident with an acute complete femoral neck fracture was not provided pain management prior to being discharged to the hospital. Resident identifiers: 298.

Inspectors wroteBased on interview and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, the DON did not work 40 hours a week.

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the low temperature dish washing machine did not reach a minimum temperature of 120 degrees Fahrenheit, a whole ham was stored above premade peanut butter and jelly sandwiches, bagged fruit, and strawberry dessert cups in the walk in refrigerator, there were onions stored on the floor of the walk in refrigerator, yogurt cups were not stored on ice on a snack cart located in a hallway, and meals were stored uncovered at the central nurse's station.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment. In addition, the facility did not establish an infection prevention and control program system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Specifically, for 2 out of 30 sampled residents, a nurse dropped a pill on the medication cart, picked up the pill with bare hands, and administered the medication to a resident. [...]

Inspectors wroteBased on interview, the facility did not ensure that the designated Infection Preventionist (IP) who was responsible for the facility's infection prevention and control program had completed specialized training in infection prevention and control. Specifically, the Director of Nursing (DON) who was the designated IP had not completed the specialized training in infection prevention and control.

Inspectors wroteBased on observation and interview, the facility did not ensure that residents have a right to a dignified existence. Specifically, for 3 out of 30 sampled residents, the facility served resident meals on disposable dishware, there were long call lights, there was a resident with socks with holes, and there were observations of staff talking down to residents in the facility. Resident identifiers: 12, 15, and 22. Findings Included: 1. On 7/28/24 at 11:46 AM, an observation was conducted of the lunch meal tray service. The mobile hot buffet was observed in the 300 hallway. Staff were observed preparing the lunch meal for residents eating in their rooms. The lunch meal was served on Styrofoam plates, disposable plastic cups, Styrofoam cups, and disposable cutlery. On 7/30/24 at 12:18 PM, an observation was made of the lunchtime hallway meal tray service. [...]

Inspectors wroteBased on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, there were several brown carpet stains found in multiple residents' rooms, there was a television antenna hanging from the ceiling of a resident room, there were damaged blinds in a resident's room, and a resident had dirty wheelchair tires from being pushed through a brown substance found on the floor of the facility. Findings Included: On 7/28/24 at 10:26 AM, an observation was made of resident room [ROOM NUMBER]. There was a large discolored area under the air conditioner near the window. There was a brownish stain on the carpet to the right side of the bed. On 7/28/24 at 12:15 PM, an observation was made of a brown substance on the floor of the bathroom in resident room [ROOM NUMBER] which had been run over by the wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that for 3 of 30 sample residents, the facility did not appropriately document the basis for the transfer or the discharge summary. In addition, appropriate documentation was not completed in order to ensure a safe and effective transition of care. Resident identifiers: 25, 47, and 298.

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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 6 out of 30 sampled residents, care plans were not created when there was a specified need and therefore were not reflective of the services required for the residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident identifiers: 7, 17, 24, 26, 32, and 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments. Specifically, or 6 out of 30 sampled residents, care plans were not updated after a change in the resident's condition or in response to implemented interventions. Resident identifiers: 3, 17, 26, 32, 35, and 298.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who needed respiratory care was provided such care care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 5 out of 30 sampled residents, the facility did not have orders for multiple residents' nasal cannulas, oxygen concentrator humidifier or oxygen concentrator to be changed nor was there any documentation that they were being changed, and a resident with an order for a mustache cannula instead received a standard nasal cannula. Resident identifiers: 7, 17, 24, 26, and 32. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 5 of ^^ sample residents were seen by the physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Resident identifiers: 7, 24, 28, 29, and 44.

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services that included the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's to meet the needs of each resident. Specifically, for 4 out of 30 sampled residents, licensed nursing staff were not signing out controlled substances and reconciling at the time of administration. Resident identifiers: 1, 3, 4, and 38.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents were free of any significant medication errors. Specifically, for 4 out of 30 sampled residents, one resident had multiple missed doses of two medications, a second resident was not administered pregabalin a time sensitive medication at the scheduled times as ordered by the physician, a third resident received a double dose of their pain and anxiety medications, and a fourth resident received a double dose of warfarin. Resident identifiers: 4, 32, 38, and 298.

Inspectors wroteBased on observation, interview, and record review, the facility did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, for 3 out of 30 sampled residents, residents that had a urinalysis (UA) collected did not have the UA completed in a timely manner. Resident identifiers: 8, 18, and 44.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure the the medical director was effective in their role of implementing resident care policies and coordinating medical care in the facility. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain records on each resident that were complete, accurately documented, and readily accessible. Specifically, for 6 out of 30 sampled residents, progress notes, an appointment referral, and Occupational Therapy orders were located in the wrong resident medical records. In addition, resident medical records were unsecured in the Director of Nursing (DON) office. Resident identifiers: 1, 3, 7, 24, 35, and 148.

Inspectors wroteBased on interview, the facility did not have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. Specifically, the facility never provided the State Survey Agency (SSA) their hospital transfer agreement.

Inspectors wroteBased on interview, the facility did not establish an infection prevention and control program (IPCP) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, the facility infection control tracking and trending was not done and the facility had not established an antibiotic stewardship program.

Inspectors wroteBased on observation and interview, the facility did not have adequate outside ventilation. Specifically, the facility was found to have numerous odors throughout the survey.

Inspectors wroteBased on interview and record review, the facility did not inform the resident representative for 2 of 30 sample residents when there was a significant change in the residents' physical, mental or psychosocial status; or when there was a need to alter treatment significantly. Specifically, two residents had a change in condition, but the facility did not attempt to contact the representative when the change of condition occurred. Resident identifiers: 25 and 46.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury. Specifically, for 2 out of 30 sampled residents, an entity report of a physical abuse allegation was not submitted to the State Survey Agency (SSA) until three days after the incident and an entity report of a neglect allegation was not reported to the SSA until 14 days after the incident. Resident Identifiers: 29 and 41. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review, in response to allegations of neglect the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 1 out of 30 sampled residents, a resident that had multiple falls and sustained an acute complete femoral neck fracture with partial displacement did not have the fracture investigated for neglect. Resident identifiers: 298.

Inspectors wroteBased on interview and record review, the facility did not accurately assess residents. Specifically, for 1 out of 30 sampled residents, range of motion impairment was not documented on the Minimum Data Set (MDS) assessment. Resident identifier: 3.

Inspectors wroteBased on interview and record review, the facility did not ensure that for 2 of 30 sample residents, a discharge summary was included in the residents' medical records. Resident identifiers: 47 and 248.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, for 2 out of 30 sampled residents, recommended treatments of daily prolonged stretching were not followed up on, occupational therapy orders were not implemented, and splints were not being provided. Resident identifiers: 1 and 35.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who enters the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary. Specifically, for 1 out of 30 sampled residents, a resident continued to have an indwelling catheter without having a diagnosis for keeping it in place. Resident identifiers: 298.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 35 medication opportunities on 7/29/2024, revealed two medication errors which resulted in a 5.71% medication error rate. Specifically, for 1 out of 30 sampled residents, a resident was administered a medication after they had consumed their meal and the physician's order documented to administer the medication before meals. In addition, the resident was administered a medication two hours after the time specified on the physician's order. Resident identifier: 4.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date as possible. Specifically, for 1 out of 30 residents, a resident's narcotic medication was being cut in half and then one-half was being placed back in the bubble pack and sealed with tape. Resident identifier: 22.

Inspectors wroteBased on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner (NP), or clinical nurse specialist. Specifically, for 2 out of 30 sampled residents, a resident had a urinalysis (UA) collected without a physician's order and a resident had a Complete Blood Count (CBC) blood lab collected without a physician's order. Resident identifiers: 8 and 18.

Inspectors wroteBased on interview and record review, the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner (NP), or clinical nurse specialist of results that fell outside of clinical reference ranges. Specifically, for 1 out of 30 sampled residents, the Medical Director (MD) was not notified timely when the x-ray results documented that the resident had an acute complete femoral neck fracture with partial displacement. Resident identifier: 298.

Inspectors wroteBased on interview and record review, the facility did not file in the resident's clinical record the signed and dated reports of radiological and other diagnostic services. Specifically, for 1 out of 30 sampled residents, a resident's ultrasound and x-ray reports were not filed in the medical record. Resident identifier:

Inspectors wroteBased on observation and interview, the facility did not dispose of garbage and refuse properly. Specifically, the facility was found to have stored uncovered, used aluminum soda cans outdoors directly outside of the kitchen.

Inspectors wroteBased on interview and record review, the facility did not arrange services with an outside agency. Specifically, for 2 out of 30 sampled residents, residents had physician's orders to follow up with a specialist and the facility staff had not made the appointments. Resident identifiers: 25 and 35.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications or refusal. Specifically, for 2 out of 30 sampled residents, residents were not provided education regarding the benefits and potential side effects of the pneumococcal immunization. In addition, the medical record did not include the administration or refusal of the pneumococcal immunization. Resident identifiers: 7 and 24.

Inspectors wrote4. Resident 9 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, paranoid schizophrenia, cognitive communication deficit, type 2 diabetes mellitus, low back pain, essential hypertension, epilepsy, and hyperlipidemia. A review of resident 9's electronic medical record was conducted. Resident 9's MDS from 7/10/22 reported that physical behavioral symptoms directed towards others was not exhibited. Resident 9's care plan updated on 7/31/22 did not have a focus area related to physical aggression towards other residents. A form titled Behavioral Care Plan from 5/13/22 was found in resident 9's paper chart. The documented stated that the problem was Aggressive Behavior with Physically combative with resident, Verbally aggressive with resident, and Anxiety circled on the document. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 8 of 33 sampled residents, that in response to allegation of abuse, the facility did not have evidence that all all leeged violation were thoroughly investigated and reported to the State Survey Agency within 5 days of the incident, and if the alleged violations were verified appropriate corrective action was taken. Specifically, there were no thorough investigations when a severly impared cognitive resident was sexually abused by a resident that was cognitively intact and when two residents were not assessed for ablitiy to consent, engaged in oral sex. These example were cited at an Immediate Jeopary level. In addition, the facility did not thoroughly investigate when a resident eloped from the facility, a resident had a bruise of unknown source and residents had a physical altercation. [...]

Inspectors wroteBased on observations, interviews and record review, it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, abuse occurred within the facility on multiple occasions,but was not identified, reported or investigated; the staffing was inadequate and resulted in falls, abuse, and activities of daily living not being completed; Quality Assurance (QA) was not completed as required for approximately one year; medically necessary appointments were not scheduled by facility staff or the administrator; wound reports and pharmacy reviews were only accessible to the Administrator, who did not provide them to nursing staff; [...]

Inspectors wroteBased on observations, interviews and record review, it was determined for 8 of 33 sampled residents, that the facility failed to protect the resident's right to be free from physical abuse and sexual abuse by other residents. Specifically, one resident with severe cognitive impairment was sexually abused by a resident that was congitively intact. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of physical abuse between residents and a bruise with an unknown origin were identified at a potiential for harm level. Resident identifiers: 7, 9, 14, 15, 26, 31, 36 and 39.

Inspectors wroteBased on interview, record review, and observation, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, residents, resident family members, and staff voiced concerns with the staffing levels. However, observations were made of the Memory Care Unit left unattended, there were not enough activity staff members, Activities of Daily Living (ADLs) were not completed, and at least one resident experienced a fall. Resident identifiers: 7, 9, 22, 26, 30, 31, 36, and 93. Findings Include: RESIDENT FALLS 1. [...]

Inspectors wroteBased on interview, record review, and interview, the facility did not develop and implement appropriate plans of action to correct identfied quality deficiencies. Specifically, multiple instances of harm or immediate jeopardy were identified during the annual recertification survey. In addition, during this survey mutliple deficiences cited on the previous annual recertification survey were not corrected, and were cited again during this survey. Resident identifiers: 4, 7, 8, 9, 10, 11, 13, 14, 15, 22, 26, 29, 30, 31, 32, 34, 36, 37, 39, 93, and 94.

Inspectors wroteBased on interview, record review, and interview, the facility did not maintain a quality assessment and assurance committee consisting of the Director of Nursing, Medical Director, and and least three other members of the facility's staff. In addition the committee did not meet quarterly.

Inspectors wroteBased on observations, interviews, and record reviews it was determined, for 2 of 33 sampled residents, that the facility did not provide residents with the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, residents were placed in the locked unit without assessments to determine if the residents met the criteria for the unit and were not provided with access codes or other information for independent egress. Resident identifiers: 7 and 9. Findings Include: Harm 1. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not provided diabetic management, antibiotics as ordered, or wound care which resulted in an amputation. Another resident was not provided treatment for a rash and the resident was unable to move in bed. These were cited at a harm level. In addition, a resident was not treated for her psoriasis. Resident identifiers: 29, 31 and 32.

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that 7 of 33 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. One resident will be cited at a harm level due to continued weight loss with no new interventions. Resident identifiers: 4, 7, 13, 31, 32, 36, and 37.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 33 sampled residents, that the facility failed to provide appropriate treatments and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, physician orders to prevent a clogged feeding tube were not followed for a resident who was receiving enteral feeding. Resident identifier: 4. Findings Include 1. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, schizophrenia, cognitive communication deficit, conversion disorder, anxiety disorder, chronic kidney disease, psychosis, difficulty in walking and hyperlipidemia. On 10/13/22 at 9:23 AM, an observation of resident 4 was made. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not ensure pain management was provided to residents who required such services. Specifically, a resident screamed out in pain when he was repositioned. Another resident went to the hospital and his scheduled pain medication was discontinued when he returned. The resident complained of uncontrolled pain. These examples will be cited at a harm level. Resident identifiers: 14 and 32.

Inspectors wroteBased on interview and record review the facility did not ensure that 4 of 33 sampled residents were free of significant medication errors. Specifically, a resident was not administered the correct dose of insulin per physician orders resulting in uncontrolled diabetes. This example will be cited at a harm level. In addition, two residents' antibiotics were not administered according to physician orders, and another resident's coumadin was not administered according to physician orders. Resident identifiers: 22, 29, 32 and 94.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not arrange outside resources in a timely manner for residents. Specifically, a resident was not scheduled for a Percutaneous Endoscopic Gastrostomy (PEG) tube placement and had multiple problems with the Nasojejunal (NJ) tube which was cited at a harm level. In addition, residents were not scheduled for a neurologist appointment and a cardiologist appointment. Resident identifiers: 4, 30 and 34.

Inspectors wroteBased on observation, interview and record review it was determined, for 10 of 33 sampled residents, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community were not provided. Specifically, residents in the memory care unit did not receive activities in the unit and activities were not provided during the day. Resident identifiers: 5, 7, 9, 13, 26, 31, 32, 35, 36, and 37.

Inspectors wroteBased on record review and interview, the facility did not have an activities program that was directed by a qualified professional who is a qualified therapeutic recreation specialist. Specifically, the facility did not employ a Certified Therapeutic Recreation Specialist.

Inspectors wroteBased on record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility did not accurately assess the residents' needs.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents were afforded the right to organize and participate in resident groups in the facility. Specifically, no resident council had been formed and held since June of 2022.

Inspectors wroteBased on interview and record review, the facility did not act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the residents deposited with the facility. In addition, the facility did not deposit resident funds into an interest bearing account. Resident identifiers: 2, 10, 28, and 30.

Inspectors wroteBased on interview and record review, the facility did not establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. In addition, the facility did not ensure that the individual financial record was available to the residents and surveyors upon request. Resident identifiers: 2, 10, 28, and 30.

Inspectors wroteBased on interview, observation and record review, the facility did not consult with 1 of 33 sample resident's physician when there was a change in the resident's status. Specifically, a resident had an ongoing rash that the physician was not notified about. Resident identifier: 32.

Inspectors wroteBased on observation and interview it was determined that the facility did not provide each resident the right to have secured and confidential personal and medical records. Specifically, resident charts were on a rolling cart that was placed in front of the memory care unit open door.

Inspectors wrote11. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, hyperlipidemia, dementia with behavioral and major depressive disorder. On 10/12/22 at 10:37 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 had dentures but the dentures were lost during the COVID-19 lock down when family could not visit. The family member stated resident 31 would wear dentures if she had them. On 10/11/22 at 7:50 AM, an observation was made of resident 31 in the memory care dining room. Resident 31 was observed to not have teeth or dentures. Resident 31's medical record was reviewed. An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 had no broken or loosely fitting full or partial denture. Resident 31 had natural teeth or tooth fragments. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 8 of 33 sampled residents, that the facility did not implement their written policies and procedures to prevent abuse and investigate any allegations. Specifically, allegations of sexual, physical abuse and a bruise of unknown origin were not reported and investigated according to facility policy and procedures. Resident identifiers: 9, 13, 14, 5, 26, 36, 31 and 39.

Inspectors wroteBased on interview and record review, it was determined the facility did not send a copy of resident 30-day discharge notices or hospitalizations to the Long-Term Care Ombudsman.

Inspectors wroteBased on observation, interview, and record review it was determined, for 10 of 33 sample resident, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, residents that had care areas trigger on the Minimum Data Set (MDS) Care Area Assessment (CAA) Summary did not have care plans developed and implemented in a timely manner. In addition, residents care plans were not updated regarding specific needs. Resident identifiers: 5, 12, 13, 14, 24, 26, 32, 35, 36 and 37.

Inspectors wroteBased on observation, interview, and record review, it was determined, for 5 of 33 sampled residents, the facility did not ensure that services provided met professional standards of quality. Specifically, a nurse did not sign out narcotics when they were administered, one resident who had not been administered their narcotic was recorded as having received the narcotic, and expired Tuberculin solution was used when determining if residents had tuberculosis. Resident identifiers: 8, 10, 11, 29 and 30.

Inspectors wroteBased on observation, interview and record review it was determined, for 7 of 33 sampled residents, based on the resident comprehensive assessments that each resident was not given appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, residents were not bathed, residents were not provided personal hygiene, residents were not provided assistance with eating, and a resident was not changed for 44 minutes after having a bowel movement. Resident identifiers: 10, 12, 13, 14, 31, 35 and 37.

Inspectors wroteBased on observation, interview and record review it was determined, for 5 of 33 sampled residents, that the facility did not ensure a resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistive devices to prevent accidents. Specifically, a resident with a history of elopements, eloped from the facility. In addition, resident's experienced repeated falls with no interventions. Another resident experienced a fall during a transfer. Resident identifiers: 24, 36, 30, 31 and 96.

Inspectors wroteBased on interview and record review, it was determined that for 5 of 33 sample residents, the facility did not provide routine and emergency drugs and biologicals to its residents. The facility did not provide pharmaceutical services to meet the needs of each resident, and did not obtain the services of a licensed pharmacist who consults on all aspects of the provision of pharmacy services in the facility. The facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. Specifically, multiple narcotic medications were not documented at the time they were administered. In addition, narcotic medications were not signed as administered in the Medication Administration Record and on the Controlled Drug Record. In addition, a third party did not reconciled narcotic medications monthly. [...]

Inspectors wroteBased on interview and record review it was determined, for 4 of 33 sampled residents, that the facility did not file, in the resident's clinical record, laboratory results that were dated and contained the name and address of the testing laboratory. Specifically, residents did not have laboratory results available to the nursing staff and results were not filed in the medical record. Resident identifiers: 2, 28, 36, and 94.

Inspectors wroteBased on observation, interview and record review it was determined, for 5 of 33 sampled residents, that the facility did not provide food prepared in a form designed to meet individual needs. Specifically, residents on mechanically altered diets were provided grapes and lettuce. Resident identifiers: 9, 22, 31, 37 and 39.

Inspectors wroteBased on observation and interview it was determined the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, frozen Mighty Shakes were observed to be thawing at room temperature.

Inspectors wroteBased on observation and interview it was determined that the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, resident's medical records were used to block an open door from the memory care unit, preventing egress.

Inspectors wroteBased on interview and record review it was determined, for 4 of 33 sampled residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized. Additionally, the facility must safeguard medical record information against loss. Specifically, narcotic medications were not reconciled monthly, nursing staff did not sign out narcotic medications, and nursing staff did not document behaviors according to physician's orders. Resident identifiers: 4, 8, 9, and 10.

Inspectors wroteBased on interview, observation, and record review, it was determined that the facility did not document the corrective actions taken by the facility after it identified incidents under the facility's infection prevention and control program (IPCP), or establish and maintain an IPCP designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a nurse did not sanitize the glucometer between residents, antibiotics for wounds did not have a corresponding culture, tuberculosis testing was not completed, TB testing was completed with expired tuberculin and staff were observed without a mask. Resident identifiers: 4, 10, 8, 11, 14, 15, 20, 29, 24, 31 and 39.

Inspectors wroteBased on interview and record review, the facility did not designate one or more individuals as the infection preventionist who are responsible for the facility's infection control program.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to test facility staff who were not fully vaccinated based on the current parameters. Specifically, there was no documentation that COVID-19 testing was completed and the results of the testing were available.

Inspectors wroteBased on observation and interview it was determined the facility did not have adequate ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were observations of urine and bowel movement odor throughout the facilty throughout the survey.

Inspectors wroteBased on observation and interview it was determined the facility did not maintain an effective pest control program so that the facility was free of pests and rodents. Specifically, a resident had a swollen eye from a bug bite, another resident collected pests in a small cup, and residents were observed with flies around them. Resident identifiers: 9, 14 and 39.

Inspectors wroteBased on observation and interview, the facility did not treat 4 of 33 sample residents with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, staff were observed to yell down the hallway during the early morning hours, staff were observed to converse in a language that was not known to a resident, a staff member was observed to speak with a resident in the locked area of the facility through the locked doors instead of face to face, residents were served on Styrofoam plates, and a resident was seated by staff facing the doors of the locked unit. Resident identifiers: 9, 25, 35 and 37.

Inspectors wroteBased on interview and record review, the facility did not convey 1 of 33 sample residents funds to his estate within 30 days of the resident's death. Resident identifier: 92.

Inspectors wroteBased on interview and record review it was determined, for 1 of 33 sampled residents, that the facility did not allow a resident's representative to access personal and medical records within 24 hours of the request. Specifically, a resident family member, a hospice representative, and the county ombudsman all requested medical records for a resident, however the records were not provided at all, or not provided within 24 hours. Resident identifier: 93.

Inspectors wroteBased on record review and interview, the facility did not include provisions to inform and provide written information to 1 of 33 sampled residents concerning the right to accept or refuse medical or surgical treatment and, at the residents' option formulate an advance directive. Resident identifiers: 35.

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 33 sampled residents, that the Minimum Data Set (MDS) assessment did not accurately reflect the resident's status. Specifically, residents dental status, dietary orders, and discharge plans were not assessed accurately. Resident identifiers: 31 and 34.

Inspectors wroteBased on interview and record review, the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 2 of 33 sampled residents. In addition, the facility did not involve the resident or the interdisciplinary team in the development of a discharge plan. Resident identifiers: 20 and 34.

Inspectors wroteBased on interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used without adequate monitoring. Specifically, residents blood pressure medications were administered when their blood pressure was outside the physician ordered parameters. Resident identifiers: 13 and 14.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility did not ensure safe and secure storage of drugs and biological's in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, tuberculin solution was expired, and narcotics were missing. Resident identifiers:

Inspectors wroteBased on interview and record review, the facility did not obtain laboratory services only when ordered by a physician for 1 of 33 sample residents. Specifically a resident had laboratory services completed without a physician's order. Resident identifier: 94.