Mountain View Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the use of bed and chair alarms (devices that contain sensors that trigger an alarm when they detect a change in pressure) to determine if utilized as restraints, to complete on-going evaluations for the continued need, and to identify a medical symptom that supported the use of the bed and chair alarms for one resident (Resident #45) out of one sampled resident. The facility census was 63. Review of the facility's policy titled, Safety and Supervision of Residents, revised July 2017, showed: - Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities; [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Residents #27 and #45) out of 16 sampled residents. The facility's census was 63. Review of the facility's policy titled, Resident Assessments, revised November 2019, showed: - All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 1. Review of Resident #27's medical record showed: - An admission date of 03/15/25; - Diagnoses of acute kidney failure; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for one resident (Resident #25) out of one sampled resident. The facility's census was 63. The facility did not provide a policy regarding the baseline care plan. 1. Review of Resident #25's medical record showed: - An admission date of 03/15/25; - Diagnosis of acute kidney failure. Review of the resident's Hospital Discharge paperwork, dated 03/15/25, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (Residents #45 and #57) out of three sampled residents receiving hospice (palliative care for the terminally ill with a life expectancy of six months or less) services had a complete hospice coordinated plan of care. The facility census was 63. Review of the facility's policy titled, Hospice Program, revised July 2017, showed: - Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was kept off the floor for three residents (Residents #16, #27, and #117) and to ensure proper drainage position of a urinary catheter drainage bag for one resident (Resident #117) out of three sampled residents. The facility failed to ensure a resident with a urostomy (a surgical procedure that creates an opening in the abdomen to allow urine to exit the body) and a nephrostomy (a thin, flexible tube inserted into the kidney through an opening in the skin to drain urine directly from the kidney) had physician orders for one resident (Resident #27) out of one sampled resident. The facility census was 63. Review of the facility's policy titled, Catheter Care, revised September 2014, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices during catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #117) out of two sampled residents, wound care for one resident (Resident #13) outside the sample of two sampled residents, and incontinent care for one resident (Resident #45) out of three sampled residents. The facility failed to utilize proper sterile technique for accessing a venous port (a medical device surgically placed under the skin in the chest area, providing access to a large vein for administering medications, fluids, or drawing blood) for one resident (Resident #27) out of one sampled resident. The facility census was 63. Review of the facility's policy titled, Catheter Care, Urinary, revised September 2014, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 66. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary and orderly environment. Observations made on 1/10/24 at 8:40 A.M. of the 100 hall showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate incontinent care was provided to prevent possible infection when staff failed to provide peri-care for two residents (Resident #1 and Resident #2) who were incontinent of urine and failed to completely clean one resident (Resident #3) who was incontinent of urine and bowel. The facility census was 65. Review of the facility's policy titled Perineal Care, dated February 2018, showed the purpose of perineal care was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 1. Review of Resident #1's face sheet (brief resident profile sheet) showed the following: -admission date of 08/22/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when staff failed to complete appropriate hand hygiene while assisting three residents (Resident #1, Resident #2 and Resident #3) with cares. The facility census was 65. Review of the facility policy titled Handwashing/Hand Hygiene, undated, showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; -Use an alcohol-based hand rub before and after direct contact with residents; -Use an alcohol-based hand rub before donning gloves; -Use an alcohol-based hand rub before moving from a contaminated body site to a clean body site during resident care; [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to store and prepare food in accordance with professional standards of practice and protect food from possible contamination when staff did not maintain clean surfaces, stored a scoop in the dry food storage bin, and staff did not wear proper facial hair or hair coverings. The facility census was 67. 1. Record review of the 2013 Missouri Food Code showed the following information: -Chapter 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils showed; (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch; (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a risk/versus benefit review for one resident's side rails (Resident #51), and failed to document alternatives attempted prior to bed rail use for two residents (Resident #51 and #17); failed to complete bed rail safety check to include measurements of the bed frame and bed rails for risk of entrapment for four residents (Residents #51, #17, #15, #46); failed to obtain physician order for the use of side rails for two residents (Resident #15 and #46), failed to obtain documented consent for use of side rails for two residents (Resident #51 and #17), and failed to address the use of bed rails in the residents' care plans for one resident (Resident #46). The facility census was 67. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a dignity bag for one resident's (Resident #23) catheter (sterile tube inserted into the bladder to drain urine) bag. The facility census was 67. Record review of the facility's policy titled' Dignity, dated February 2021, showed the following: -Residents are treated with dignity and respect at all times; -Demeaning practices and standards of care that compromise dignity are prohibited; -Staff are expected to promote dignity and assist residents to keep urinary catheters (a sterile tube inserted in the bladder to drain urine) bags covered. 1. Record review of Resident #23's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 11/20/18; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff developed, reviewed, and revised one resident's (Resident #11) comprehensive care plan to include wandering and elopement behaviors. The facility census was 67. Record review of the facility's policy titled care plan, dated 2001, revised 2006, showed the following information: -The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; -Completed care plans are placed in the resident's chart; -Certified Nurse's Aides/CNA's, are responsible for reporting to the nurse supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved; [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement physician orders of Two-Cal (a liquid dietary supplement) and calcium for one resident (Resident #46), who had a history of weight loss. The facility census was 67. Record review of the facility's policy, titled nutrition (impaired)/unplanned weight loss-clinical protocol, dated September 2017, showed the following information: -The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time; -The staff and physician will define the individual's current nutritional status and identify individuals with anorexia (lack or loss of appetite for food), weight loss or gain, and significant risk for impaired nutrition; [...]