Mountain View Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure inventions were implmented to safeguard, protect, and prevent the elopement (an instance where a resident leaves the facility without authorization and/or necessary supervision) for 1 of 3 residents (Resident 1) reviewed for accidents and hazards. This deficient practice placed residents at risk for serious injury and the potential for future elopements.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free of abuse for 1 of 3 residents (Resident 1) reviewed for abuse. This deficient practice placed residents at risk for physical injury, psychosocial distress, and feeling unsafe in their home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. The failure to consistently monitor kitchen refrigerator temperatures for 2 of 2 kitchen refrigerators, and the failure to ensure undated/expired foods were discarded for 1 of 1 nutritional refrigerator (resident snack refrigerator), placed residents at risk for ingestion of contaminated food or beverages, cross contamination, and potential of food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement components of their infection prevention and control precautions regarding, A) the water management program (WMP) control measures (actions or steps taken), identified to reduce the potential growth/spread of Legionella (a bacteria that can cause a severe respiratory disease) in water, when not within acceptable ranges for 1 of 1 WMP reviewed for infection control and, B) respiratory devices were not cleaned/disinfected for 1 of 3 Residents (Resident 30), reviewed for respiratory care. This failure placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.

Inspectors wroteBased on interview and record review the facility failed to implement their abuse/neglect policies and procedures to identify allegations of neglect filed as grievances for 10 of 44 grievances from 12/01/2025 to 02/23/2026) reviewed for neglect allegations. The facility did not provide a thorough investigation into the allegations of neglect to determine if further action to protect the residents was required. The lack of recognizing allegations of neglect and taking appropriate action placed residents at risk for a deterioration in their physical and or mental health.

Inspectors wroteBased on interview and record review, the facility failed to ensure investigations were completed and/or thorough for 3 of 5 residents (Resident 22, 4, and 52) reviewed abuse. The failure to initiate and complete thorough investigations placed residents at risk for unidentified accidents, abuse/neglect and serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of competent nursing staff to provide care and services for 4 of 4 residents (Residents 5, 2, 3, and 35 ) as evidenced by failures related to Resident Rights, Activities of Daily Living (ADLs), Quality of Care, and Prevention or Decrease in Range of Motion. Additionally, reports in the facility grievance logbook showed allegations of neglect in care and staff interviews provided additional evidence of insufficient staff. This failure placed residents at risk of not having their needs met and potential/actual negative outcomes to their physical and mental health. Review of the 2025 Facility Assessment, updated 01/13/2026, showed on Section A. Function and Mobility for Activities of Daily Living (ADL) excluding bathing which required assistance was 87% of the facility residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable and sanitary environment was maintained for 8 of 12 resident rooms (Rooms 3, 4, 5, 6, 9, 18, 21 and 25), 1 of 1 utility room (East hallway) and 1 of 1 kitchen reviewed for environment. This failure placed the residents at risk for potential accidents and not feeling safe/secure with their environment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who required assistance with incontinence received timely care to maintain their dignity for 1 of 2 residents (Resident 11) reviewed for dignity. Resident 11 requested assistance with an incontinence episode however staff told them they would have to wait until other staff were available to help them. This failure placed the resident at risk for unmet care needs, embarrassment, potential skin injuries and a deterioration in their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide required liability notices for 1 of 3 residents (Resident 78) reviewed for liability notices. Failure of the facility to issue a Notification of Medicare Non-Coverage [NOMNC] or Advanced Beneficiary Notice [ABN] (required notifications informing Medicare beneficiaries that their covered services will be terminated and providing information on their appeal rights) before discharge from the facility placed Resident 78 at risk for not fully understanding their Medicare benefits and appeal rights.

Inspectors wroteBased on interview and record review the facility failed to ensure resident grievances were promptly followed up on by coming to a resolution of the grievance for 2 of 5 residents (Residents 5 and 4) reviewed for grievances. Additionally, the facility did not keep the residents updated on the progress of their grievances. This failure placed residents at risk for overall dissatisfaction with their lives and unresolved concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic (drugs that change brain chemistry to alter a person's mood, thoughts, behavior, or perceptions) medications when they did not consistently attempt non-pharmacological (non-drug, strategies used first to manage mental health symptoms) interventions prior to medication use and failed to adhere to the 14-day limitation for PRN (as needed) psychotropic medications for 1 of 5 residents (Resident 35), reviewed for unnecessary medication. This failure placed residents at an increased risk for falls, medication-related adverse side effects, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent showers, incontinent care, oral care, and nail care for 2 of 5 residents (Residents 2 and 3) reviewed for activities of daily living (ADL). The failure to receive adequate showering and grooming care according to the residents' physician orders and care plan placed the residents at risk for unmet care needs, impaired skin integrity, and a potential decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received the necessary care and services to maintain their highest practicable physical well-being in accordance with professional standards of care by failing to ensure proper immobilization, and failing to consistently follow physician's orders to oversee the healing process for 1 of 3 resident (Resident 35) reviewed for falls with injury. This failure placed Resident 35 at risk for further injury, impaired healing, and a decline in range of motion (ROM).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided for 1 of 4 residents (Resident 2) reviewed for positioning. There were no assessments, specific interventions to mitigate the risk of contractures (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) or Restorative nursing for Range of Motion (ROM) services to prevent further decrease in range of motion and hand contracture. This failure placed the residents at risk for a decrease in mobility, development/worsening of contractures and inability to maintain their current level of functioning.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure drugs and biologicals were stored, labeled, and monitored in accordance with professional standards. The facility failed to discard expired or improperly labeled medications on one of three medication carts (East medication cart) and failed to document twice-daily temperature monitoring for 1 of 1 medication refrigerator in medication storage room. These failures placed residents at risk for receiving compromised or ineffective medications and vaccines and negative health outcomes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine and timely dental services were provided and failed to follow through on practitioner-ordered referrals for 3 of 5 residents (Resident 52, 53 and 41) reviewed for dental care. This failure placed the residents at risk for dental pain, nutritional compromise and unmet dental needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents/resident representatives (RR) were educated on the potential risk versus benefits when offering the pneumococcal and influenza immunization (specific vaccines that protects against pneumococcal bacteria and influenza viruses that can lead to lung, nose and throat infections) nor documentation that indicated vaccination were offered, accepted or refused for 2 of 5 residents (Resident 22 and 2) reviewed for immunizations with infection control. This failure placed residents at risk of exposure to contagious diseases without the knowledge of the risk/benefits in order to make an informed decision.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representative (RR) were offered/educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) immunization (a specific vaccine for the COVID-19 virus) benefits/risks and potential side effects for 2 of 5 sampled residents (Resident 22 and 2) reviewed for immunization status. This failure placed the resident and/or their representative at risk of making an uninformed decision and resident contracting the COVID-19 virus.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate care and services were provided to maintain Range of Motion (ROM) for 3 of 3 residents (Residents 1, 3, and 2) reviewed for Restorative Nursing programs. The lack of consistent processes in place for implementation of splints and providing ROM services placed residents at risk for not maintaining ROM in the affected areas of contractures (tightening of tendons and muscle), decreased function and pain.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure cleaning, disinfecting and/or storing of oxygen care equipment was maintained in a manner to prevent infectious diseases for 3 of 5 residents (Residents 4, 5 and 6 ) reviewed for cleanliness of oxygen concentrator (a device that pulls air out of the environment and concentrates into oxygen) filters and storage of oxygen tubing when not in use. This failure placed residents at risk for infectious disease transmission and illness in their respiratory system (lungs).

Inspectors wroteBased on interview and record review, the facility failed to accurately assess/reassess and provide adequate supervision and safety monitoring for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1, who had moderately impaired cognition and lacked safety awareness, experienced harm when they exited the facility unsupervised, was subsequently found by a bystander outside the facility, lying on the ground and sustained a head injury, left elbow fracture, and multiple bruises that required a hospital evaluation and intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of chemical restraints for 1 of 3 residents (Resident 5) reviewed for unnecessary medications. This deficient practice placed residents at risk of experiencing unnecessary side effects such as sedation, decline in physical functioning, and placed residents at risk of experiencing an undignified life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the components for identification and reporting abuse/neglect from their abuse prohibition policy were implemented for 1 of 5 residents (Resident 5) reviewed for abuse and neglect. This deficient practice placed residents at an increased risk for unidentified abuse and neglect and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of potential abuse and/or neglect to the State Agency (SA) as required for 1 of 5 residents (Resident 5) reviewed for abuse and neglect. This deficient practice placed residents at risk for unidentified abuse/neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication administration practices were maintained in accordance with professional standards of nursing practice for 1 of 3 residents (Resident 5) reviewed for medication administration. This deficient practice resulted in Resident 5 receiving a chemical restraint and placed other residents at risk for receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent showers for 3 of 9 residents (Residents 1, 3, and 4) reviewed for activities of daily living (ADL) care provided for dependent residents. The failure to receive adequate showering and grooming care according to the residents' care plan placed the residents at risk for unmet care needs, impaired skin integrity, and embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from neglect for 1 of 3 residents (Resident 1), reviewed for neglect, when they failed to perform consistent skin assessments as ordered and failed to obtain and implement wound treatment orders when Resident 1 developed a new skin concern. Resident 1 experienced harm when they developed a necrotic (death of tissue) area to the right foot and fifth (little) toe which required hospitalization and surgical intervention of a partial amputation of the right foot (side of foot) including the little toe.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were bathed, free from odors and provided a dignified dining experience for 5 of 5 sampled residents (Residents 13, 14, 25, 27, and 7) reviewed for dignity. These failures placed residents at risk for feelings of embarrassment, helplessness, and a diminished self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure a prompt effort to resolve grievances (a concern that has happened or been done that you believed was unfair) was made regarding resident grievances discussed during Resident Council (RC, an independent group of nursing home residents who meet at a minimum of once a month to discuss concerns and suggestions and to plan activities that are important to them) meetings nor the residents right to file a grievance/grievance process for 4 of 5 residents (Residents 6, 12, 13, and 14) reviewed for grievances. This failed practice placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were completed or correct on/after residents admission to the facility and had the required level two referral sent if residents had a positive level one PASARR for 4 of 7 residents (Resident 9, 263, 56, 4) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans, nor provide a summary of the required information from the BCP upon completion of the comprehensive care plan to the resident or the resident ' s representative for 5 of 10 newly admitted residents (Residents 49, 62, 60, 263, and 48) reviewed for baseline care plans. This failure placed the residents at risk for a lack of knowledge regarding the initial plan for delivery of care/services and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were consistently reviewed and revised to meet residents' current needs for 5 of 12 sample residents (25, 30, 13, 4, and 17) reviewed for care plans. Additionally, the facility failed to complete care conferences for 1 of 3 residents' (Resident 4) reviewed for resident/resident representative participation in care conferences. These failures to revise care plans and complete care conferences, define changes and allow resident participation in planning their care, placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician assistance for a resident with a mental health and substance use disorder (SUD, a medical condition that is defined by the inability to control the use of a particular substance or substances despite harmful consequences) history, provide ongoing assessment and monitoring of identified non-pressure skin conditions, and provide care for a peripheral IV line for 3 of 4 residents (Residents 263, 28, and 13) reviewed for quality of care. These failures placed residents at risk for delay of treatment, unmet care needs, and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment and services were provided to increase, maintain and/or prevent a decline in Range of Motion (ROM) mobility for of 4 of 6 residents (Residents 13, 14, 25 and 42) reviewed for limited ROM and restorative nursing services. The facility's failure to have a process in place that ensured timely processing of the program, assessment, and implementation of restorative nursing programs, placed residents at risk for not maintaining gains made while on skilled therapy, functional decline, increased dependence on staff for Activities of Daily Living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of nursing staff to provide care and services for 12 of 13 residents (Residents 13, 14, 25, 27, 6, 22, 37, 28, 263, 30, and 42) as evidenced by failures related to Resident Rights, Grievances, Activities of Daily Living (ADLs, daily actions like dressing, transferring/getting a resident up out of bed, changing briefs/toileting), Quality of Care, Resident Mobility, and Facility Assessment. Additionally, resident interviews and staff interviews provided evidence of insufficient staff. These failures place residents at risk for unmet care needs and the inability to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure cleaning, disinfecting and/or storing of oxygen care equipment was maintained in a manner to prevent infectious diseases for 3 of 3 residents (Residents 1, 36, and 35)reviewed for cleanliness of oxygen concentrator (a device that pulls air out of the environment and concentrates oxygen for use) filters and 1 of 2 residents (Resident 25) reviewed for storage of oxygen tubing when not in use. These failures placed residents at risk for infectious disease transmission and illness in their respiratory system (lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable and sanitary environment was maintained for 1) 2 of 3 halls (East and West) flooring, 2) East dining room, 3) [NAME] Hall shower room, 4) rooms [ROOM NUMBERS], 5) Laundry room, 6) East clean/dirty utility room, and 7) Conference/activities room. These failures placed the residents, at risk for potential accidents and the exposure to contaminants from unclean surfaces.

Inspectors wroteBased on observation, interview, and record review the facility failed to comprehensively assess and monitor the need for a physical restraint (any physical, mechanical device or equipment that limits a resident ' s freedom of movement) when a seat belt was applied during the resident use of their electric wheelchair, for 1 of 2 residents (Resident 17) reviewed for physical restraints. This failure placed the resident at risk for a restriction of their free movement and/or activity and at an increased risk for injury when in their electric wheelchair.

Inspectors wroteBased on interview and record review the facility failed to ensure implementation of their abuse prohibition policy/procedures components of resident protection, identification, reporting and investigating for 4 of 4 residents (Resident 41, 28, 42, and 27) reviewed for abuse/neglect. This failure placed the residents at an increased risk for unidentified abuse/neglect, retaliation from the alleged perpetrator and the potential for continued exposure to abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes) for 1 of 2 residents (Residents 60) reviewed for transfer/discharge notice requirements. This failure placed the residents at risk for diminished protection from inappropriate transfers/discharges, a lack of access to an advocate that could inform them of their options/rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to a transfer or discharge.

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of the resident ' s hospital transfer for 1 of 2 residents (Residents 60) reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold while in the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement comprehensive resident centered care plans for 2 of 6 residents (Residents 21 and 56) reviewed for care plan development. This failed practice put residents at risk for unmet care and/or safety needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent showers for 2 of 5 residents (Residents 37 and 22) reviewed for activities of daily living (ADLs). The failure to receive adequate showering and grooming care according to the residents' care plan placed the resident at risk for unmet care needs, impaired skin integrity, and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who used chewing tobacco was assessed for 1 of 3 sampled residents (Resident 30) reviewed for smoking/chewing tobacco. This failure placed the resident at risk for interaction of medications with ingredients in chewing tobacco and/or with current health concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident on continuous oxygen that required a Bipap device (an external device that helps you breathe by pushing pressurized air into your lungs and provides a fixed pressure to keep breathing airways open while you sleep) was used for 1 of 2 residents (Resident 25) reviewed for respiratory care. The failure of staff to assess and document Resident 25's refusal to use their Bipap device placed Resident 25 at risk for ineffective assisted ventilation and unmet respiratory needs.

Inspectors wroteBased on interview, and record review, the facility failed to identify and implement specific requirements for the timely administration of an immuno-suppressive medication Tacrolimus (used to prevent the body from rejecting a transplanted organ) for 1 of 5 residents (Resident 4) reviewed for high-risk medications. Additionally, the specific instructions for the medication were not included on the medication administration record (MAR) to ensure licensed nurses were aware of the importance with closely following the medication administration times to maintain steady levels of Tacrolimus in the blood. This failure placed Resident 4 at risk for low therapeutic blood levels of the immuno-suppressive medication and increased the risk for rejection of their transplant organ.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) for 2 of 5 residents (Residents 21 and 263) reviewed for unnecessary medications. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide palatable, and warm meals at the proper temperature for 4 of 8 residents (4, 23, 41 and 48) reviewed for appetizing food and drink. This failure placed the residents at risk for less-than-adequate nutritional intake potentially leading to weight loss and dissatisfaction with their dining experience.

Inspectors wroteBased on interview and record review, the facility failed to A) update the assessment when a substantial change occurred when the facility experienced a change in ownership, and B) update the assessment when substantial changes occurred for sufficient staffing when the facility lost their access to a nursing assistant training program that helped fill nursing assistant vacancies. These failures placed residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the cognitive capacity to understand the nature and implication of entering into a binding arbitration agreement (an alternative means of settling disputes without a jury by trial) for 2 of 3 residents (Resident 52 and 21) reviewed for arbitration. This failure placed the residents at risk for a lack of understanding of the legal contract they had signed and their right to make a choice for a jury trial in the event of a dispute with the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were educated on the risks and benefits of the influenza vaccine, and consent or declination were obtained for the vaccine for 2 of 5 sampled residents (Residents 14 and 27) reviewed for influenza immunization. This failure placed residents at risk of not being fully informed before making decisions regarding immunizations and receiving the vaccine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing information was being posted in a place readily accessible to residents/visitors and included the required information on 3 of 7 days (01/08/2025, 01/09/2025, and 01/13/2025) of the recertification survey. This failure placed residents, family members and visitors at risk of not being fully informed of current staffing levels and resident census information.

Inspectors wroteBased on interview and record review, the facility failed to timely complete, thoroughly investigate, and provide prompt resolutions for grievances filed for 5 of 9 residents (Resident 1, 2, 3, 4, and 5) reviewed for grievances. This deficient practice placed residents at risk for unmet care needs and the potential for unidentified abuse and/or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility to maintain their Respiratory Protection Program (RPP) for N95 respirator masks (a respiratory protective device designed to filtrate airborne particles by achieving a very close facial fit) related to fit testing for 2 of 4 staff (Staff F and G) and appropriate wear for 3 of 6 staff (Staff E, H, and I) reviewed for infection control practices during a COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) outbreak. This deficient practice placed residents and staff at continued risk of exposure and spread of COVID-19 during an active outbreak.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received physician ordered medication, had necessary laboratory values (labs) drawn as ordered, and received timely treatment for abnormal labs for 4 of 4 residents (Residents 1, 2, 3, and 5) reviewed for quality of care. This failed practice resulted in harm for Residents 1 and 2 when their treatment was delayed, conditions worsened, and required hospitalization. Residents 3 and 5 were at risk for their condition to worsen and experience inaccurate or a delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff compliance with current infection control guidelines and standards of practice by 1) incorrectly donning/doffing (to put on/to take off) personal protective equipment (PPE) for 4 of 7 staff (Staff K, F, T, and U), 2) not adhering to fit testing (to ensure a proper fit) guidelines for N-95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) for 5 of 5 staff (Staff G, I, M, N, and O), and 3) improper hand hygiene and glove changes for 4 of 7 staff (Staff K, F, T, and U) between dirty and clean tasks when providing care and services to residents on transmission based precautions ([TBP], safeguards to prevent spread of diseases) during a COVID- 19 (an infectious disease-causing respiratory illness with symptoms [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the provider of an elevated heart rate and a low blood pressure for 1 of 3 residents (Resident 4) reviewed for change in condition This failure placed the resident at risk of inappropriate medication dosages, health complications, and timely care of services from the physician, resulting in a delay of treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the provider (physician or nurse practitioner) following a resident's complaint of new onset chest pain for 1 of 2 residents (Resident 22) reviewed for change in condition. The failure to notify the provider in a timely manner resulted in harm to Resident 22 when they experienced distress, delay in treatment, and prolonged pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services that addressed skin infections and accurate blood pressure treatments were provided in accordance with professional standards of practice for 2 of 5 residents (Residents 44 and 13) reviewed for quality of care. This failure resulted in actual harm to Resident 44 when they experienced unnecessary pain, emotional distress and a decline in their medical condition, and caused unmet care needs and placed Resident 13 at risk for negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and interventions to ensure the safety of 1 of 2 residents (Resident 26) reviewed for falls. This failure resulted in actual harm to the resident who experienced two falls within 10 hours, that resulted in a major injury; the first fall resulted in a head trauma with a laceration; the second fall resulted in a pelvic fracture.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident representative a summary of the baseline care plan for 4 of 5 residents (Resident 33, 38, 149, and 43) reviewed for baseline care plans. This failure placed the residents at risk for an unsafe environment, a delay in care and services, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive assessments and care plans prepared by the required members of the interdisciplinary team (a group of healthcare providers from different fields who work together for the best outcome for residents) for 4 of 4 residents (Residents 43, 44, 27, and 153) reviewed for comprehensive care planning. This failure placed the residents at risk of unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication error rate of less than five percent. Five medication errors were identified for 3 of 9 residents (Residents 40, 19, and 249) observed during 31 medication administration opportunities, that resulted in an error rate of 16.13%. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible and possible adverse side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standard infection control interventions, intended to mitigate the risk for transmission of infectious diseases, were consistently implemented in the areas of: A) Transmission based precautions (TBP- standard precautions [minimum infection prevention practices that apply to all patient care] along with additional precautions for residents that may be infected with certain infectious diseases) for 2 of 2 residents (Residents 151, and 38) reviewed for TBP; B) Personal protective equipment (PPE) for 1 of 3 residents (Resident 38) reviewed for PPE in TBP rooms; C) Medication administration for 4 of 4 residents (Residents 38, 40, 42, and 32) reviewed for infection control practices during medication administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that prompt efforts were made to resolve grievances for 1 of 2 sampled residents (Resident 6) reviewed for grievances. The failure to promptly attempt to resolve grievances disallowed the resident their right to a timely grievance resolution and placed the resident at risk for dignity and financial concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an incident involving an unwitnessed event with substantial (of considerable importance) injury was reported to the State Agency (SA) as required for 1 of 2 resident (Resident 26) reviewed for falls with injury. The failure to report an unwitnessed fall that resulted in a substantial bodily injury, placed the resident at risk for further injury, harm and potential neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 2 of 6 residents (Residents 27 and 19) reviewed for residents' dependent on staff for personal grooming and hygiene. The failure to provide the necessary care and services to dependent residents placed them at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received proper treatment and assistive devices to maintain vision abilities for 1 of 2 residents (Resident 20), reviewed for vision. Failure to ensure residents received vision care and assistive devices placed the residents at risk for worsening vision. <Resident 20> Review of Resident 20's electronic medical record (EMR), showed they were admitted to the facility on [DATE] with diagnoses including depression, presbyopia (loss of the eye to focus on objects closely), diplopia (a condition of the eye that caused double vision), and cataracts (cloudy patches that covers the eye causes blurred vision). The 10/19/2023 comprehensive assessment showed Resident 20 required partial or substantial assistance of one staff member for activities of daily living (ADLs) and an intact cognition. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two of three medication carts (South and East Hall medication carts), reviewed for medication storage, were secured. This failure placed residents at risk for access to potentially harmful medications and negative health outcomes

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that 1 of 3 residents (Resident 1) reviewed for indwelling urinary catheters (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), was referred to a urologist for evaluation of the continued need for the urinary catheter. Resident 1 experienced harm when after nine months of use, they experienced a urethral (a tube that connects the urinary bladder to an opening for the removal of urine from the body) erosion (a place where surface tissue has been gradually destroyed) pressure injury (localized damage to the skin as well as underlying soft tissue sometimes related to medical devices).

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and resident representative of an injury for 1 of 1 resident (Resident 1) reviewed for a change in condition. This failure placed the resident at risk for a delay in medical treatment and of not having a resident representative involved in health care decision making.