Mountain View Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, record review, and facility policy the facility failed to implement changes to the Care Plan for 1 of 14 Sampled residents, (R46).

Inspectors wroteBased on interview, record review, review of the facility's local health department inspection, and review of the local health department's website, the facility failed to provide education to food handlers related to safe food handling practice to enable the food handlers to effectively carry out the functions of the food and nutrition service department. This deficient practice affected 53 residents receiving meals from the kitchen.

Inspectors wroteBased on observation, interview, and review of the facility's policies, it was determined the facility failed to provide a safe sanitary environment for food production and appropriate trash storage and disposal, which affected 54 residents receiving their meals from the kitchen.

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were labeled with residents' names. Observation of the four (4) medication carts and two (2) medication refrigerators on 07/16/2024 at 2:08 PM and 2:13 PM and on 07/18/2024 at 4:36 PM, revealed three (3) of the four (4) carts contained unlabeled medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure accurate assessments for one of 29 sampled residents. The facility failed to document Resident (R) 25's skin lesion identified on 10/07/2022 until the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/2024. Review of the facility's policy titled, Resident Assessment Instrument (RAI) Process, dated 10/2019, revealed the facility will use the most current version of the RAI Manual and follow guidelines therein as set forth by the Centers for Medicare and Medicaid services (CMS) for all RAI processes and completion of the MDS unless otherwise outlined in the manual. Further review revealed the facility will complete the RAI process according to state guidelines as applicable. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that included instructions needed to provide effective and person-centered care of the resident (R) to meet professional standards of quality care for one of 29 residents sampled for care plans, R49.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, to include measurable objectives and timeframes as identified in the comprehensive assessment for two of 29 residents sampled for care planning, R10 and R39. 1. The facility failed to implement R10's care plan related to respiratory care, to include ensuring the resident's supplemental oxygen was running at the prescribed liters per minute. Observation on 07/17/2024, revealed R10's oxygen running at 2.5 liters per minute (LPM); however, the Physician's order was for the resident to receive her oxygen at 4 LPM. 2. In addition, the facility failed to add resident-centered interventions regarding R39's repeated refusals of his dressing changes for his wound.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care consistent with professional standards for 1 of 3 residents (R) sampled for respiratory care (R10), out of the total sample of 29 residents.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy it was determined the facility failed to immediately notify the physician of omitted medications and/or medication errors for twelve (12) of twenty-two (22) sampled residents (Resident #3, #9, #13, #19, #28, #41, #42, #47, #63, #66, #72, and #86). Seven residents (Residents #3, #13, #19, #41, #42, #72, and #86), who were alert and oriented, all alleged they did not receive medications as ordered on the evening of 08/19/19. RN #1 was responsible for administering medications for these residents on 08/19/19. Although the residents' complaints were reported to administrative staff (DON and Administrator), the facility failed to report the medication errors to the residents' physicians. Resident #66 also reported that he/she did not receive his/her medications on the evening of 08/26/19. [...]

Inspectors wrote***The facility alleged the following was implemented to remove the Immediate Jeopardy as of 09/19/19: 1. On 09/13/19, a Quality Improvement meeting was conducted after the Immediate Jeopardy (IJ) was communicated to the facility. The purpose was to develop an improvement plan to address the IJ deficiencies, and monitor guidelines to ensure compliance was maintained. This meeting was attended by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and an RN Nurse Consultant. 2. On 09/14/19, the facility's Medical Director was made aware of the Immediate Jeopardy and advised of the improvement plan, by the DON. He had no concerns or additions to the plan. 3. On 09/16/19, a follow-up QI meeting was conducted to review the progress on the 09/13/19 plan. A review of all items completed and the monitoring plan was completed. [...]

Inspectors wrote2. a. Review of the medical record for Resident #63 revealed the facility admitted the resident on 06/25/19 with diagnoses that included Seizure, Debility, Acute Renal Failure, and Hypertension. Review of the MDS dated [DATE] revealed the resident had a BIMS score of eight (8), which indicated the resident was cognitively impaired but interviewable. Further review of the medical record for Resident #63 revealed Physician's Orders for Phenobarbital 64.8 milligrams (mg), one tablet by mouth twice daily for seizures. The medication was scheduled to be administered at 10:00 AM and 10:00 PM; and Depakote 500 mg, one tablet by mouth three (3) times per day, used to treat seizures, was scheduled for 10:00 AM, 2:00 PM, and 10:00 PM. Review of the Medication Administration Record (MAR) dated 08/26/19, revealed the medications had not been initialed as being administered for the 10:00 PM dose. [...]

Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to maintain a system of records to ensure the accurate reconciliation of controlled drugs. Nursing staff failed to document that narcotic counts were completed by two (2) nurses at shift change, 46 times between 08/21/19 and 09/10/19. The controlled medication count on 9/18/19 was inaccurate for one resident's (Resident #33) medication.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice in two (2) of two (2) medication storage rooms and during observation of the medication pass on 09/09/19. Observation of the facility's East and [NAME] medication rooms revealed expired medications available for resident use. Observation of the medication pass on 09/09/19 revealed a bottle of prescription nasal spray sitting on top of the medication cart and not under the direct physical supervision of a licensed nurse or medication aide.

Inspectors wroteBased on observation and interview, it was determined the facility failed to store, serve, and prepare food under sanitary conditions. During the initial tour of the kitchen, slices of pie were observed stored on a cart in the walk-in cooler, uncovered and not dated. During the lunch tray line observation, wrapped silverware was observed to be contaminated with food that could not be identified. In addition, staff was observed to transport an uncovered food tray to the [NAME] Wing at the supper meal on 09/08/19.

Inspectors wroteBased on interview, record review, and review of the facility policy it was determined the facility failed to have an effective performance improvement program which measured the success and tracked the performance of implemented plans to ensure improvements are sustained in the facility. The State Agency received an acceptable Plan of Correction (POC) on 11/14/19 for previously cited deficiencies, with an exit date of 09/25/19. Per the POC, the facility conducted weekly audits to ensure the Shift Change Controlled Substance Count Check sheets included two (2) staff members' signatures (on-coming and off-going nurse and/or medication aide). [...]

Inspectors wroteBased on observation and interview, it was determined the facility failed to provide a sanitary homelike environment for residents. Observations of the lunch meal service in the dining room on 09/08/19 revealed the facility had two (2) separate dining services at different times for the lunch meal (A dining and B dining). Staff failed to clean the dining room tables between the A and B dining services. Observations revealed residents who ate at the B dining service were observed to sit and eat at tables contaminated with food spillage from the previous A dining service.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to maintain an effective pest control program to ensure the facility was free of pests. Flies were observed in the kitchen on initial tour, during the lunch meal, and during the supper meal on 09/08/19. An air curtain over the facility kitchen door to the outside was observed, but it was not functioning. There was no other means to prevent or control flies in the kitchen.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to report an allegation of verbal abuse for one (1) of twenty-two (22 ) sampled residents (Resident #10) to the appropriate entities including the State Survey Agency within two (2) hours of becoming aware of the allegation. The facility received a report of verbal abuse on 07/07/19 at 1:00 AM from Resident #10 that he/she had been verbally abused by Registered Nurse (RN) #1. However, the facility failed to report the alleged abuse to the State Survey Agency until 9:17 AM on 07/08/19 (over 20 hours after the allegation was initially reported by the resident).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to protect and prevent further abuse for one (1) of twenty-two (22) sampled residents (Resident #10). On 07/07/19, Resident #10 alleged verbal abuse from Registered Nurse (RN) #1 when she told the resident to shut up and go to his/her room. RN #1 was not removed from direct resident care and was permitted to continue to work until her shift was completed. Resident #10 slept on another unit, away from the RN.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure seven (7) unsampled residents received or were offered appealing options (substitutes or alternates) of similar nutritive value when the residents chose not to eat food that was initially served, or who had requested a different meal choice.