Mountain View Post Acute

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#2) of three residents was kept free from physical abuse out of six sample residents. Specifically, the facility failed to protect Resident #2 from physical abuse by Resident #3.

Inspectors wroteBased on observations and interviews the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and three of three nourishment rooms. Specifically, the facility failed to:- Ensure employees performed hand hygiene appropriately;- Ensure food was labeled, dated and stored appropriately; - Ensure dishes were washed and sanitized at the correct temperature,- Ensure equipment was stored properly; and,- Ensure the nourishment room refrigerators were clean and maintained at safe temperatures.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide adequate outside ventilation by means of windows and/or mechanical ventilation in four of four shower rooms. Specifically, the facility failed to ensure the residents' shower room vents were functioning in four shower rooms.

Inspectors wroteBased on observation and interviews, the facility failed to treat each resident 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 in two of two dining rooms. Specifically, the facility failed to:-Provide a meal in a timely manner and did not notify the residents of the delay,-Serve residents at a table at the same time, and-Provide residents on the Monarch who were sitting in the dining room waiting for their meal that was delayed, with a drink or diversion.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a comfortable and homelike environment for residents on three of four units. Specifically, the facility failed to:-Ensure residents were provided clean washcloths;-Ensure broken towel racks and window seals in residents room were fixed timely,-Ensure residents' rooms were clean; and,-Ensure the lights in the residents' shower room were fixed timely.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure four (#44, #74, #62 and #82) of six residents reviewed for activities out of 53 sample residents received an ongoing program of activities , designed to meet the needs and interests, and promote physical, mental and psychosocial well-being. Specifically, the facility failed to offer and provide personalized and group activity programs for Resident #44, #74, #62 and #82.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for five of 10 residents reviewed on the secured unit out of 53 sample residents. Specifically, the facility failed to keep five resident beds in a safe position to prevent accident hazards.

Inspectors wroteBased on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for three out of five certified nurse aides (CNA) reviewed. Specifically, the facility failed to ensure CNA #3, CNA #4, and CNA #5 received 12 hours of continuing education annually.

Inspectors wroteBased on record review and interviews, the facility failed to inform residents of the possible outcome of their noncompliance with nutritional supplements for one (#62) out of three residents reviewed for weight loss out of 53 sample residents. Specifically, the facility failed to inform Resident #62 of the risks of significant weight loss.

Inspectors wroteBased on record review and interviews, the facility failed to protect two (#111 and #66) of eight residents from abuse out of 53 sample residents. Specifically, the facility failed to protect Resident #111 and Resident #66 from physical abuse from each other.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#93) of three residents out of 53 sample residents received the proper treatment and assistive devices to maintain vision. Specifically, the facility failed to:-Follow up after an eye appointment for Resident #93; and,-Assist Resident #93 to make an appointment for cataract surgery.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning procedures for cleaning and disinfecting resident rooms and high-frequency touched areas; and ,-Ensure housekeeping staff performed hand hygiene and glove changes appropriately.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure the call light system was functioning properly in its entirety. Specifically, the facility failed to ensure staff could hear the call light alerts when working in areas away from the centralized staff work area, where the call light alarm sound was heard when there were no staff in the centralized work area to hear the alarm.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#6) of three residents out of seven sample residents received the highest practicable treatment and care per professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure Resident #6 received her medications in a timely manner, as prescribed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain and maintain the highest practicable mental and psychosocial wellbeing for one (#2) of three residents reviewed out of five sample residents. Specifically, the facility failed to ensure services and individualized care approaches were provided, and monitored with ongoing assessment, for Resident #2 in order to meet the emotional and psychosocial needs of the resident.

Inspectors wroteBased on record review, observations and interviews, the facility failed to establish a system of records and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to determine that drug records are in order and that an account of all controlled substances is maintained and periodically reconciled. Specifically, the facility failed to: -Maintain a system of controlled substance records for discontinued controlled substances.

Inspectors wroteBased on observation, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for one (#11) of three residents reviewed for services to maintain highest practicable quality of life out of 25 sample residents. Specifically, the facility failed to provide timely incontinence care for Resident #11.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (#2, #12 and #7) out of 25 sample residents. Specifically, the facility failed to: -Ensure the physician's orders for skin and wound care were followed for Residents #2 and #12; and, -Ensure Resident #7 received medication as ordered by the physician.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure nursing staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP).

Inspectors wroteBased on observations, record review and staff interviews the facility failed to provide services according to professional standards of practice for one (#1) out of three sample residents. Specifically, the facility failed to monitor Resident #1, who had a change of condition after suspected illicit drug use.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure two (#93 and #62) of three out of 51 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure: Resident #93, who was at high risk for developing pressure wounds and an increased risk for developing infections, developed a sacral skin wound on 5/25/23 that progressed to a stage 4 sacral pressure wound. The facility failed to ensure effective and timely interventions were in place to prevent Resident #63 from the development of pressure wounds. The facility failed to assess, monitor and document skin assessments and pressure wounds. The facility failed to place timely interventions in the prevention of the development and progression of the pressure wound. [...]

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure for four (#75, #79, and #111) of five residents reviewed received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being, out of 54 sample residents. Specifically, the facility failed to follow physician orders for significant weight loss, consistently put interventions in place and timely address Resident #75 nutritional needs. Specifically, the facility failed to follow physician orders for weight loss, consistently put interventions in place and timely address Resident #79 nutritional needs. Resident #75 experienced a significant, unplanned weight loss of 12 % in three months. Resident #79 experienced an unplanned weight loss of 5.56 % in one month. [...]

Inspectors wroteBased on interviews, observations and record review, ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to: -Ensure resident food was palatable in taste, temperature, texture and appearance; and, -Address resident food complaints. I. Facility policy and procedure The Food and Nutritional Services policy, revised September 2017, was provided by the nursing home administrator on 11/16/23 at 4:34 p.m. It revealed in pertinent part, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. II. Resident and resident representative interviews All residents were identified by facility and assessment as interviewable. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; -Follow accepted hand hygiene practices during meal preparation; and, -Kitchen and food service areas were kept clean

Inspectors wroteIII. Water testing failure A. Professional reference According to CDC, Legionella (Legionnaires 'Disease and Pontiac fever), last reviewed 3/25/21, retrieved from on 11/28/23: https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html. It read in pertinent part, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires ' disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on the hand held shower hose in room [ROOM NUMBER], #1308 and the shower room on 1400 hall, increasing the risk of contamination to the facility's main water supply.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were treated with dignity for five (#29, #35, #45, 85 and #329) of six reviewed out of 54 sample residents. Specifically, the facility failed to: -Ensure residents were treated with dignity when staff failed to respond timely to call lights for Residents (#29, #35, #45, #85, #329); -Ensure staff provided a structured daily routine when possible for dementia care; and, -Ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served their meals.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents, in 22 of 105 resident rooms in six hallways. Specifically, the facility failed to -Ensure heating units in resident rooms and in common resident shared areas were in good repair; and, -Ensure that the walls, baseboards, ceilings, counters, and doors in resident rooms and common resident areas were properly maintained.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for seven out of nine incidents of abuse involving 11 residents (#99, #27, #19 #230, #98, #61, #4, #78, #24, #79 and #60) out of 54 sample residents. Specifically, the facility failed to: -Ensure that Resident #27, Resident #19 and Resident #230 on the Columbine unit were not subject to physically abusive behavior by Resident #99; -Ensure Resident #99, who had a history of dementia and physical aggression towards other residents, received adequate supervision and implementation of effective personalized interventions to prevent the resident from abuse other vulnerable residents; -Ensure abuse prevention and protection interventions for Resident #27 and #19 were assessed, documented and implemented: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for five (#90, #83, #42, #79, and #85) of 6 out of 51 sampled residents. Specifically, the facility failed to consistently provide person-centered approaches to Residents #90, #83, #42, and #79, who had diagnoses of dementia, involved in resident to resident altercations on the secured unit (cross-reference F600 for abuse).

Inspectors wroteBased on observations, record review and interviews, the facility failed to assist one (#38) of two residents reviewed for preferences out of 54 sample residents. Specifically, the facility failed to: -Ensure staff provided assistance and encouragement for the resident (#38) to treat the edema in both of his lower legs; -Ensure the resident could comfortably elevate his legs while in his bed and in his room; -Ensure resident was treated with kindness, respect and dignity when he practiced self advocacy to alter his environment to meet his needs; and, -Ensure the resident ' s care plan was updated timely to reflect the Resident #38 ' s unique needs and preferences within his environment that facilitated the treatment of the edema in his legs.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to investigate one allegation of resident to resident altercation physical abuse for two (#29, and #99) of five residents reviewed for abuse of 54 sample residents.

Inspectors wroteBased on record review and interviews the facility failed to complete and transmit encoded, accurate Minimum Data Set (MDS) data to the CMS (Center for Medicare and Medicaid Services) system for one (#58) of three out of 54 sample residents. Specifically, the facility failed to complete MDS Discharge assessment upon Resident #58 ' s discharge from the facility to the community.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure activities designed to support residents' physical, mental and psychosocial well-being were provided for one (#51) of four residents reviewed for meaningful activity programming activities out of 54 sample residents. Specifically, the facility failed to ensure: -Resident #51 received individualized meaningful activities to meet her social, emotional and recreational needs; -Resident #58 was consistently offered her eyeglasses so she could see fine details and possibly participate in preferred independent activities; and, -Review with Resident #58 her activity preferences and update the resident ' s changes in activity preferences on a quarterly basis.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure supervision and assistive devices to prevent accidents for one (#186) of three residents reviewed for falls of 54 sample residents. Specifically, the facility failed to implement fall prevention care planned interventions for resident #186 who experienced several recent falls.

Inspectors wroteBased on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#185, and #2) of four residents reviewed for supplemental oxygen use out of 54 sample residents. Specifically, the facility failed to administer oxygen therapy at the appropriate rate/ liter flow in accordance with the physician's order for Residents #185 and #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (#66) of two residents ' reviewed for dialysis out of 54 sample residents. Specifically, the facility: -Failed to ensure communication between the dialysis center and the facility; -Failed to have a physician's order for dialysis treatment or orders to assess the shunt site for thrill and bruit (for blood flow); -Failed to consistently assess the shunt site for thrill/bruit and the resident post dialysis; and, -Failed to have an individualized person-centered dialysis care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide food that accommodated resident allergies, intolerances and preferences for three (#87, #84 and #53) of three residents out of 54 sample residents. Specifically, the facility failed to: -Ensure Resident #87 received an accommodation for a food allergy and food intolerance by receiving her preferred beverage for her morning cereal and coffee; -Ensure Resident #84 received his preferred side of brown sugar with his morning oatmeal; and, -Ensured that Resident #53 received his preferred breakfast meal.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure each resident received their meals, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Specifically, the facility failed to ensure the residents did not have prolonged wait times of 30 minutes or longer for their meal to be served; and that meals were served to the residents at the regular posted meal times.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#185) of three residents reviewed for hospice services out of 54 sample residents. Specifically, the facility failed to: -Have a written plan of care for Resident #185, including both the most recent hospice plan of care and a description of the services furnished by the long-term care (LTC) facility; and -Ensure that facility staff provided orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff who provide resident care in the facility environment.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#43) of five residents reviewed for immunizations out of 54 sample residents. Specifically, the facility failed to offer and provide the pneumococcal conjugate vaccine (PCV13) and or pneumococcal polysaccharide vaccine (PPSV23) to Resident #43.

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served in the dining room.

Inspectors wroteBased on observations, record review and interviews, the facility failed to meet professional standards of quality for two (#30 and #11) of four residents reviewed of 30 sample residents. Specifically, the facility failed to ensure scheduled medications were given to Resident #9, #10, #11 and #12 in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) receives the necessary services and assistance during showers and baths for three (#2, #8 and #3) of three residents reviewed for hygiene assistance of 30 sample residents. Specifically, the facility failed to provide scheduled showers and baths or offer an alternative for Resident #2, #8 and #3.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide sufficient nursing staff to ensure the residents receive the care and services they required in keeping with their comprehensive plans of care, to achieve and maintain their highest practicable physical, mental and psychosocial well-being. Specifically, -Eight interviewable residents (#5, #4, #20, #22, #24, #26, #12 and #3) out of 30 sample residents and two family members said the facility failed to provide sufficient staff which resulted in delayed and/or inadequate care; -Observations made during survey from 9/14/23 to 9/27/23 revealed care and services not being provided timely; and, -Call lights not accessible to residents. Cross-reference citations: -F550 the facility failed to honor residents rights to timely meal service. -F658 the facility failed to provide medications timely. [...]

Inspectors wroteBased on interviews, observations and record review,ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to: -Ensure resident food was palatable in taste, temperature, texture and appearance; and, -Address resident food complaints. I. Facility policy and procedure The Food and Nutritional Services policy, revised September 2017, was provided by the nursing home administrator on 9/27/23 at 4:14 p.m. It revealed in pertinent part, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. II. Resident and representative interviews All residents were identified by facility and assessment as interviewable. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to the facility failed to ensure drinks and other fluids were provided and consistent with the care plan, preferences and choices. Specifically, the facility failed to consistently offer, encourage and provide fluids for residents in between meals.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for pressure injuries received care consistent with professional standards of practice to prevent pressure injuries out of 30 sample residents. Specifically, the facility failed to implement interventions to prevent pressure injuries for Resident #4, who was at risk for pressure injuries.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide necessary ostomy care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#6) of one resident reviewed for ostomy care out of 30 sample residents. Specifically, the facility failed to provide routine monitoring of the coloostomy ensuring the coloostomy was not leaking and properly secured to Resident #6.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for two (#4 and #8) of five residents reviewed for vaccinations of 30 sample residents. Specifically, the facility failed to ensure Resident #4 was educated on refusal of pneumococcal and Resident #8 received pneumococcal immunization.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to store and prepare foods under sanitary conditions. Specifically, the facility failed to ensure that: 1. Dietary staff properly restrained hair in the kitchen; 2. Raw eggs were stored below ready-to-eat items; 3. Dietary staff washed their hands and used gloves properly; and 4. Items were dated and labelled in the resident nourishment refrigerators and expired items were discarded.

Inspectors wroteBased on observations, record review, and interviews with residents and staff, the facility failed to ensure water that was accessible to residents was maintained at safe temperatures at all times in seven of 14 hallways.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to serve palatable meals to five (Resident #84, Resident #119, Resident #134, Resident #55, and Resident #44) of five residents observed meal service.

Inspectors wroteBased on observations, interviews, and review of facility documents, the facility failed to provide residents with meals at regular times consistent with posted mealtimes and resident preferences for 136 of 136 residents who receive meals from the kitchen, and failed to provide snacks for residents who wanted to eat outside of scheduled meal service times.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to update person-centered care plans to reflect changes in interventions for one (Resident #84) of five residents reviewed for accidents. Specifically, the facility failed to update the accident/falls care plans with additional interventions after falls occurred for Resident #84.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to provide medically related social services for one (Resident #55) of one sample resident reviewed for discharge planning. Specifically, the facility failed to ensure transition of care services were provided when Resident #55 requested a transfer to another facility.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure its medication error rate was not 5% or greater. There were five errors out of 38 opportunities observed for two (Resident #84 and Resident #86) of five residents, which resulted in a medication error rate of 13.16%.