Mountain View Manor

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that a resident representative was notified of an accident involving the resident, which resulted in injury, to one of three sampled residents (#21). The deficient practice could result in harm to the resident without their representative being aware.

Inspectors wroteBased on observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that adequate supervision was provided to prevent one resident (#3) from wandering into other resident rooms. The deficient practice may result in higher liklihood of wandering and reduced safety for the residents.

Inspectors wroteBased on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to implement their policy on sexual contact between two residents (#7 and #9) who were not adequately assessed for capacity and consent. The deficient practice could allow for ongoing incidents which could lead to harm of a resident.

Inspectors wroteBased on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to report to the state agency that two residents (#7 and #9) who were not adequately assessed for capacity and consent had sexual contact. The deficient practice could allow for ongoing incidents not being reported which could lead to harm.

Inspectors wroteBased on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to investigate sexual contact between two residents (#7 and #9) who were not adequately assessed for capacity and consent. The deficient practice could allow for ongoing incidents of sexual abuse, which could lead to harm of a resident.

Inspectors wroteBased on observation, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#7) was free from an accident of elopement. The deficient practice could lead to accidents resulting in harm to residents.

Inspectors wrote-Resident #223 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident was cognitively intact. The MDS further revealed no indicators for mood or behaviors and that the resident had upper extremity impairment on both sides and lower extremity impairment on one side; required partial/moderate assistance with toileting hygiene, personal hygiene and substantial/maximal assistance rolling left and right. [...]

Inspectors wrote-Resident #49 was admitted to the facility on [DATE] with diagnoses that included myelodysplastic syndrome, unspecified and anemia, unspecified. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS further revealed that the resident needed partial to moderate assistance rolling left and right, and the helper does less than half of the effort in the process. During an interview with resident #49 on February 28, 2025 at 9:26 AM it was revealed that on the night of Monday, February 24, 2025 at 11:02 PM the resident pushed her call light button and the Certified Nursing Assistant (CNA/staff #23) responded ten minutes later. Upon entering the room, staff #23 opened the door and turned on the light. [...]

Inspectors wroteBased on clinical record review, interviews and facility policy review, the facility failed to ensure medical records were completed and accurately documented for three residents (#49, #36, and #223). The deficient practice may result in the incompletely kept medical records and not being accurate.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and facility policy, the facility failed to ensure 2 residents (#36, #7) were treated with dignity and respect. The deficient practice has the potential for additional residents to be treated with a lack of dignity and respect.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directives were completed and maintained for one of three sampled residents (#10). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life.

Inspectors wroteBased on clinical record review, interviews, observations, facility documentation, and policies, the facility failed to ensure that an allegation of abuse was reported to mandatory reporting agencies within the required timeframe for one resident (#49). The deficient practice could result in abuse allegations not being reported.

Inspectors wroteBased on staff interviews and policy review, the facility failed to ensure a list of monthly resident discharges was submitted to a representative of the Office of the State Long-Term Ombudsman. The deficient practice resulted in the ombudsman not being notified of transfers or discharges.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the state mental health authority was notified of a resident's change in mental condition for one resident of two sampled residents (#31). The deficient practice could result in residents not receiving the proper level of care to meet their needs.

Inspectors wroteBased on clinical record review, staff interviews and policy review and AHCCCS Medical Policy Manual, the facility failed to ensure that a staff member was responsible to complete the required assessments for PASRR to meet the residents' needs. The deficient practice could result in residents not receiving appropriate care and treatment related to Serious Mental Illness (SMI) and Mental Illness (MI).

Inspectors wroteBased on clinical record review, staff and resident interviews, and policy and procedure, the facility failed to ensure that pain medication was administered according to physician orders for two of seventeen sampled residents (#224 and #12). The deficient practice could result in overmedication for residents.

Inspectors wroteBased on clinical record review, staff interviews, observations, and policy review, the facility failed to ensure that medications were not left unattended on a bedside table for one of 22 sampled residents (#423); and failed to ensure that medications were stored in a secure manner that would prevent accident hazards. The deficient practice may result in accidental self-administration and/or undesirable medication induced harm.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure one resident (#224) was provided respiratory care consistent with professional standards. The deficient practice could result in respiratory complications.

Inspectors wroteBased on clinical record reviews, staff interviews, and review of policy and procedure, the facility failed to ensure target behavior and adverse side effects related to psychotropic medication use were monitored for 7 of 9 sampled residents (#6, #24, #29, #38, #40, #109 and #110). The deficient practice could result in unnecessary medication use and adverse side effects.

Inspectors wrote-Resident #40 was readmitted to the facility on [DATE] with diagnoses including primary hypertension, type 2 diabetes mellitus with hyperglycemia and bipolar disorder. Review of the Pre-admission Screening and Resident Review (PASRR) Level 1 screening document dated 09/13/22 did not include a diagnosis of bipolar disorder. There was no primary diagnosis of dementia or Alzheimer's disease documented. The form documentation included the resident was not prescribed psychotropic medications at the time of the review or within the 6 months prior. The form was marked for exemption related to admission meeting criteria for 30 day convalescent care. The form indicated no referral necessary for any Level 2. [...]

Inspectors wroteBased on clinical record reviews, staff interviews, and policy and procedures, the facility failed to ensure that comprehensive care plans were developed for 5 residents (#40, #110, #109, #29 and #28). The sample was 16. The deficient practice may result in an incomplete plan of care for residents.

Inspectors wrote-Resident # 19 was admitted on [DATE] with diagnosis that included; Unspecified fracture of right femur, subs for closed fracture with routine healing, need for assistance with personal care. The MDS (minimum data set revealed) dated October 10, 2022 revealed resident had a BIMS score of 11 indicating the resident had moderate cognitive impairment. Per the assessment, the resident required extensive two-person physical assistance with dressing and total dependence with bathing; required limited assist with toileting, transfers and bed mobility; had moisture associated skin damage (MASD); and, was at risk for developing pressure ulcers. Review of the Quarterly Care Plan dated November 22, 2022 revealed resident required extensive assistance for all activities of daily living (ADL's). [...]

Inspectors wroteBased on clinical record review, staff interviews, and review facility documents and policy, the facility failed to ensure resident #62 received treatment and care to prevent hospitalization. The deficient practice had the potential to cause harm.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that pressure ulcer assessments were completed in accordance with professional standards of practice for one of three sampled residents (#29). The deficient practice could result in pressure ulcer not assessed, monitored and treated.

Inspectors wroteBased on clinical record review, staff interviews and policy and procedures, the facility failed to ensure physician visits are conducted at the required intervals for two residents (#6, and 29). The sample size is 9. The deficient practice may cause delay in comprehensive assessment of resident's health status and unmet health care needs.

Inspectors wroteBased on the clinical record review, resident and staff interviews and review of facility assessment, documentation, policy and procedure, the facility failed to ensure that there was sufficient nursing staff to meet the needs of the residents. The deficient practice could result in residents needs not met.

Inspectors wroteBased on interview, record review and findings of past three years of recertification surveys, the facility failed to implement and maintain the Quality Assurance and Performance Improvement (QAPI) program to make good faith attempts to correct quality deficiencies. Failure to maintain the QAPI program placed all residents at risk for injury or illness related to adverse events such as falls, weight loss, and psychological impact.

Inspectors wroteBased on personnel file reviews, staff interviews, and review of facility policy and procedure, the facility failed to ensure that 3 of 10 sampled staff (#1, # 5, and #31) were provided training on abuse and residents rights. The deficient practice could result in staff not being educated to protect residents from abuse and to provide the appropriate services to residents.

Inspectors wroteBased on clinical record review, staff interviews and review of policy, the facility failed to ensure one resident and/or their representative (#110) were informed regarding the risks, benefits and alternatives to psychotropic medication prior to administration. The sample size was 16. The deficient practice could result in residents and/or their representatives not being fully informed of the risks, benefits and alternatives to proposed treatment.

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy and process, the facility failed to provide one resident (#28) with a copy of his medical records within the required timeframe. The deficient practice could result in residents not being aware of medical conditions and health care needs.

Inspectors wroteBased on clinical record review, staff and resident interviews, and the facility policy and process, the facility failed to ensure one resident (#28) was not abused by a staff (#18). The deficient practice could result in other residents being abused.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to provide care that met professional standards for respiratory equipment for one resident (#19) and the facility failed to ensure medications were administered as ordered for one resident (#11). The deficient practice could interfere with the flow of oxygen and adverse effects for residents; and could result in inadequte treatment of diagnosed conditions.

Inspectors wroteBased on observations, review of the clinical record, staff interviews, and review of facility policy, the facility failed to provide respiratory care according to the physician order for one resident (#110). The deficient practice could result in adverse respiratory outcomes for residents.

Inspectors wroteBased on record review, staff interviews, and facility policy and procedures, the facility failed to ensure a pharmacist recommendation related to the PRN (as needed) antipsychotic medication was reviewed and acted upon for one resident (#38). The sample size was 5 residents. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon.

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy and process, the facility failed to ensure rehabilitation services was provided to one resident (#28) as ordered by the physician. The deficient practice could result in residents not receiving rehabilitation needed to maintain or improve their physical health.

Inspectors wroteBased on personnel file review, interviews, and Federal guidelines, the facility failed to ensure 2 of 2 sampled staff (#13 and #39) had evidence of continuing competencies of no less than 12 hours per year of required in-service training. The facility census was 63. The deficient practice could result in inadequate care for residents.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure that one resident (#3) and/or their representative was informed of the risks and benefits of psychotropic medications prior to the administration of the medications. The sample size was 5 residents. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and the potential adverse side effects of psychoactive medications.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that two residents (#39 and #16) were not administered unnecessary medications, by failing to ensure that medications were administered in accordance with physician ordered parameters. The sample size was 6. The deficient practice increases the risk for medication-related side-effects.

Inspectors wroteBased on clinical record review, staff interviews, and facility policies, the facility failed to ensure that one resident (#3) had adequate indications for the use of psychotropic medications and adequate monitoring of the psychotropic medications being received. The sample size was 5 residents. The deficient practice could result in residents receiving unnecessary psychotropic medications.

Inspectors wroteBased on observations, clinical record reviews, staff interviews, and review of policy and procedure, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered to four residents (#19, #21, #35, and #239). The error rate was 13.79%. The deficient practice could result in further medication errors.

Inspectors wroteBased on facility documentation, staff interviews, facility policy, and the Center for Disease Control (CDC) recommendations, the facility failed to designate a qualified Infection Preventionist (IP) on an ongoing basis. The facility census was 38 residents. The deficient practice could lead to improper infection prevention practices within the facility.

Inspectors wroteBased on clinical record review, staff interviews, facility document and policy and procedure review, the facility failed to ensure a resident (#38) was free from neglect. The census was 38. The deficient practice could result in residents being subjected to neglect.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure review, the facility failed to ensure a thorough investigation of an allegation of neglect was completed for one resident (#38). The census was 38. The deficient practice could result in incomplete investigations of allegations of neglect.

Inspectors wroteBased on clinical record reviews, staff interviews, review of facility policy and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for two residents (#3 and #16) related to medication use. The sample size was 12. The deficient practice could result in inaccurate resident assessments.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a care plan was implemented for one resident (#10). The sample size was 12. The deficient practice could result in residents not receiving care that are recommended per care plan.

Inspectors wroteBased on clinical record review, facility document, resident and staff interviews, and review of policy and procedure, the facility failed to ensure the clinical record was accurate and complete for one resident (#38) regarding bowel movement documentation. The sample size was 12. The census was 38. The deficient practice could result in residents' clinical record not being accurate and complete.