Mountain View Rehabilitation and Care Center

Inspectors wroteBased on interview and record review, the facility failed to honor resident rights related to providing care and treatment for chemotherapy for 1 of 1 resident (Resident 36). This failure placed residents at risk of unmet medical needs, emotional upset, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received the necessary care and services to attain or maintain their highest practicable level of well-being for 2 of 2 residents (Resident 82 and 94) reviewed for quality of care. These failures placed all residents at risk of developing wounds, worsening wounds and other skin conditions and diminished care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure developed interventions (fall mats and call lights) were in place to minimize the risk for injury during a fall for 1 of 2 sampled residents (Residents 26) reviewed for accident hazards. This failure placed residents at risk for potential injury, negative outcomes and decreased quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to ensure treatment carts and medication carts were locked for 1 of 1 treatment carts (Treatment Cart 1) and 1 of 4 medication carts (Medication Cart C). These failures placed residents at risk for having access to treatment supplies and medication not prescribed to them, missing medication, and access to medication by unauthorized individuals.

Inspectors wroteBased on interview and record review, the facility failed to identify the resources needed and provide the necessary care and services the resident requires during day to day operations according to the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents). The facility failed to provide care and treatment for chemotherapy for 1 of 1 resident (Resident 36). This failure placed residents at risk of unmet medical needs and delays in care, treatment and service needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system in which resident's records were complete, accurate, and accessible, for 1 of 1 resident (Resident 36) reviewed for accurate and complete medical records. The facility failed to ensure the residents' medical records contained weekly laboratory results and accurate documentation about appointments placed residents at risk for medical complications, unmet care needs, and for diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to notify the responsible party when a medication order had been changed for 1 of 1 (Resident #1) residents reviewed for a change of condition. The failure to not inform the resident representative of a high-risk medication change placed them at risk not to be informed of the risks and benefits and violated a resident right to be involved in health care decision making.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, and homelike comfortable environment. The facility failed to provide necessary housekeeping and maintenance of resident rooms, bathrooms, and hallways; failed to ensure comfortable sound levels were maintained, failed to ensure resident rooms were individualized with items to provide a homelike environment, and failed to ensure residents were afforded adequate living space. These failures placed residents at risk for a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, were completed within the required timeframes and/or included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 9 of 22 residents ( 4, 5, 20, 55, 51, 62, 66, 70 and 179) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) accurately reflected the current status for two of seven residents (Residents 45 and 50) and failed to ensure two of seven residents (Resident 5 and 56) were referred for level two evaluations. These failures placed the residents at risk for inappropriate placement and not receiving timely and necessary services to meet mental health care needs. <RESIDENT 50> Resident 50 admitted to the facility 11/01/2023 with diagnoses that included depression and Klinefelter Syndrome (genetic condition in which a male has an extra X chromosome which may delay developmental milestones). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure three (5, 20, and 50) of six residents reviewed for unnecessary medications, staff failed to followed provider orders in regard to weights and blood sugar (the amount of glucose in your blood) monitoring. These failures placed residents at potential risk of a decline in medical status and quality of life-related to unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate indications for use of an antipsychotic medication (medications that affect the mind or behavior) for 3 of 6 residents (Residents 5, 179 and 380), failed to ensure residents were monitored for adverse consequences of psychotic medication use for 2 of 6 residents (Residents 45 and 380), failed to ensure behaviors were monitored for 2 of 6 residents (Residents 45 and 380) and failed to obtain consents timely for 1 of 6 residents (Resident 179) reviewed for unnecessary medications. These failures put the residents at risk for experiencing adverse side-effects from unnecessary medication use.

Inspectors wroteBased on interview and record review, the facility failed to identify a Significant Change in Status for 1 of 3 sampled residents (Resident 229) reviewed for hospice services. Failure to identify and complete a Significant Change in Status (SCSA) assessment placed residents at risk for inadequate care planning and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a hearing impairment had a base line care plan developed and implemented to provide effective and person-centered care for 1 of 1 resident (Resident 380) reviewed for base line care plans. This failure placed residents at risk of not being informed of their initial plan for delivery of care and services and placed them at risk for unmet needs and possible complications.

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans for 1 of 3 residents for falls (179), and 1 of 5 residents for nutrition (20). The failure to review and revise care plans by the interdisciplinary team after each assessment placed the residents at risk for unmet care needs, feelings of boredom, agitation and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with 2 of 3 dependent residents including meal assistance for resident (4) and bathing for resident (179) reviewed for activities of daily living (ADL's). Facility failure to provide resident's, who were dependent on staff for assistance with hygiene including eating assistance and showers placed residents and others at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 residents (Resident 45) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift for 5 of 6 days (01/02/2025, 01/03/2025, 01/06/2025, 01/07/2025, and 01/08/2025), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on interview, and record review, the facility failed to address emotional and psychosocial well-being through assessment, care plan development and implementation for one of two residents (53), reviewed for individualized behavioral health needs. This failure placed residents at risk of unmet emotional and psychosocial health needs, unwanted behaviors, and a decreased quality of life.

Inspectors wroteBased on observation, and interview the facility failed to ensure one of four medication carts had unsecured medications. In addition, the facility failed to ensure medications were secured and not accessible to residents for two of two (70 and 75) residents. These failures placed residents at risk for unauthorized access to medications and biologicals, and potential drug misuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure prompt dental services were provided for 2 of 3 sampled residents (Residents 33 and 56) reviewed for dental services. This failure placed residents at increased risk for continued dental problems, difficulty chewing, associated health complications, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed infection control procedures and practices for 1 of 2 residents (Resident 229) on enhanced barrier precautions (EBP) that were observed for care. The facility also failed to disinfect resident care equipment between resident use. These failures placed residents at risk of cross contamination and/or the spread of disease.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure appropriate interventions were used to prevent the spread of germs for 3 of 4 residents (Residents 1, 2, and 3) reviewed for wound care. Failure to change gloves and complete hand hygiene when indicated during incontinent care and wound care placed residents at risk for the transmission of germs, including the potential for a wound infection.

Inspectors wroteBased on interview and record review, the facility failed to follow consultant recommendations for 1 of 2 residents (Resident 4) reviewed for wound clinic visits. Failure to follow up and/or implement consultant recommendations placed residents at risk of complications of health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 3 sampled residents (Residents 4, 2, and 5) reviewed for diabetes (disease where body does not use sugar effectively) remained free of significant medications errors related to the administration of insulin (high-risk medication for diabetes). Failure to administer insulin within the required time frame of one hour before/after the scheduled time parameter placed residents at risk of abnormal blood sugars (level of sugar in blood that is monitored for residents with diabetes).

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 3 of 5 sampled residents (Resident 1, 2, and 3) reviewed for admission orders. Failure to implement and follow physician prescribed orders on admission to the facility placed residents at risk of medical complications and a decline in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed a physician's order with a prescribed oxygen (O2) flow rate (the amount of supplemental oxygen flowing over a certain length of time) and indication for use was completed for 2 of 8 sampled residents (Resident 275 and 222) and failure to ensure respiratory equipment and tubing was regularly cleaned and/or changed and dated for 6 of 8 sampled residents (Resident 275, 33, 42, 12, 225, and 222) reviewed for respiratory care. This failure placed the resident at potential risk for respiratory distress, respiratory infection, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were provided education about COVID-19 (an infectious respiratory disease caused by a virus) vaccination for 2 of 4 staff (Staff J and K) reviewed for employee COVID-19 immunizations. Failure to educate staff regarding the risks, benefits, and potential side effects of Covid-19 vaccination placed the staff at risk for having insufficient information to make informed decisions.

Inspectors wroteBased on interview, and record review, the facility failed to provide a written notice to the resident, resident's representative(s) and representative of the Office of the State Long-Term Care Ombudsman of an emergency transfer for 4 of 4 sampled residents (Residents 25, 45, 46, and 53) reviewed for hospitalizations. This failure did not afford resident and/or their representative to make informed decisions about transfers and prohibited access to an advocate who could inform resident/representative of their options and rights. This failure had the potential to affect all facility-initiated discharges.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff contacted the Level II evaluator for a Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) Level II assessment (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) for 1 of 6 residents (Resident 21) reviewed for PASRR. Failure to update the PASRR with a change in mental health condition placed the resident at risk of health and/or emotional decline related to a lack of professional evaluation to determine if mental health interventions were required.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a discharge plan addressed the discharge needs for 1 of 3 sampled residents (Resident 71) reviewed for effective discharge planning. These failures placed the resident at risk of not having necessary medications available and for not having hospice care coordinated for after discharge.

Inspectors wroteBased on observation, and interview, the facility failed to provide the necessary assistance with grooming (nail care) for 2 of 6 sampled residents (Resident 51 and 3) dependent on staff to ensure their needs were met per their individual preferences. The failed practice placed residents at risk for medical complications, poor quality of life and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 53) reviewed for Mobility/Limited Range of Motion (ROM), received appropriate treatment and services to prevent further decrease in ROM. This failure placed the resident at risk for development of contractures (joint becomes fixed in place) and further decline in ROM.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with indwelling urinary catheters (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) received appropriate treatment and services to prevent catheter-associated urinary tract infections (CAUTIs) for 2 of 3 sampled residents (Resident 45, and 48) reviewed for indwelling urinary catheter care/management. The facility failed to develop individualized plans for the prevention of CAUTIs including to develop individualized and specific clinical indications for changing the catheters and/or catheter bags. These failures placed residents with indwelling urinary catheters at an increased risk for UTI's and associated complications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (Resident 48) reviewed for unnecessary medications. Failure to re-evaluate the need for continued use of antibiotic medications placed residents at potential risk for use of unnecessary medications and/or have adverse side effects.

Inspectors wroteBased on interview and record review the facility failed to provide 5 of 10 sampled residents (Resident 71, 225, 33, 42, and 275) and/or their representatives with a summary of their baseline care plan with 48 hours of admission. This failure placed residents at risk of not being informed of their initial plan for delivery of care and services to work on resident specific goals.