Mountain View Skilled Nursing Community at Wlrc

Inspectors wroteBased on observation, staff interview, record review, facility investigation review, and policy review, the facility failed to protect the residents' right to be free from verbal abuse, physical abuse, and sexual abuse by staff and residents for 3 of 8 sample residents (#4,#12,#16) reviewed for allegations of abuse and neglect. This failure resulted in actual harm to resident #16.

Inspectors wroteBased on staff interview, medical record review, policy review, and facility incident investigation review, the facility failed to ensure adequate supervision was provided for 2 of 8 sample residents (#2, #14) reviewed for accident hazards. The failure resulted in actual harm to resident #2.

Inspectors wroteBased on staff interview, medical record review, facility investigation review, professional standard review, and policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 8 sample residents (#10) reviewed for quality of care.

Inspectors wroteBased on medical record review, staff interview, facility incident review, and policy review, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 of 13 sample residents (#2, #3) reviewed for allegations of abuse. This failure resulted in actual physical harm to resident #2 and resident #3.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to ensure necessary behavioral health care and services were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 13 sample residents (#1) who was reviewed for behavioral health interventions. This failure resulted in actual harm to resident #1.

Inspectors wroteBased on facility incident report review, state survey agency incident database review, staff interview, and policy and procedure review, the facility failed to ensure timely reporting of allegations of abuse for 2 of 13 sample residents (#1, #2) reviewed for allegations of abuse.

Inspectors wroteBased on medical record review, staff interview, and policy and procedure review, the facility failed to provide a written notice of transfer for 1 of 2 sample residents (#4) reviewed for facility-initiated transfers.

Inspectors wroteBased on medical record review, staff interview, and policy and procedure review, the facility failed to provide written information on the bed-hold policy for 1 of 2 sample residents (#4) reviewed for facility-initiated transfers.

Inspectors wroteBased on medical record review and staff interview, the facility failed to arrange for specialized services to meet the resident's needs as identified on the Preadmission Screening and Resident Review (PASARR) level II for 1 of 2 sample residents (#9) reviewed.

Inspectors wroteBased on medical record review, staff interview, policy and procedure review, and review of CDC immunization recommendations, the facility failed to ensure residents were offered pneumococcal immunizations based on CDC recommendations for 1 of 5 sample residents (#3) reviewed for immunizations.

Inspectors wroteBased on staff interview and policy and procedure review, the facility failed to conduct an annual review of its infection prevention and control program (IPCP). The census was 13.

Inspectors wroteBased on observation, staff interview, review of policy and procedures, and 2022 FDA Food Code review, the facility failed to ensure a sanitary environment in 2 of 2 food preparation areas (main kitchen, Sunflower cottage). The census was 8.

Inspectors wroteBased on resident fund account review, staff interview, and facility investigation review, the facility failed to protect the residents' right to be free from misappropriation of resident property by a staff member for 5 of 9 sample residents (#2, #3, #4, #5, #6). Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 9/1/23.

Inspectors wroteBased on medical record review, staff interview, and policy and procedure review, the facility failed to ensure target symptoms were identified related to the use of psychotropic medications for 3 of 5 sample residents (#1, #2, #8) reviewed for unnecessary medications.

Inspectors wroteBased on medical record review, staff and resident interviews, and review of incident reports and facility documentation, the facility failed to protect the resident's right to be free from physical abuse by a client from another facility for 1 of 1 sample residents (#1) reviewed for abuse allegations, which resulted in physical and psychosocial harm. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 10/6/23.

Inspectors wrote2. Review of physician orders for October 2022 showed resident #53 had orders for quetiapine (anti-psychotic) 125 mg via g-tube (gastrostomy tube, a type of feeding tube) every day at bedtime for major depressive disorder and unspecified intracranial injury with loss of consciousness, and escitalopram (anti-depressant) 20 mg by mouth every day in the morning for major depressive disorder. Further review showed the resident had diagnoses which included intracranial injury with loss of consciousness, major depressive disorder, epilepsy and epileptic syndromes with complex partial seizures, and dysphagia. Review of the care plan last revised 7/11/22 showed problems which included Behavioral Symptoms: [Resident] has displayed disruptive verbal aggression towards residents and staff. [...]

Inspectors wroteBased on medical record review, staff interview, and policy and procedure review, the facility failed to provide a written notice of transfer for 1 of 1 sample residents (#57) reviewed for facility-initiated transfers.

Inspectors wroteBased on medical record review, staff interview, and policy and procedure review, the facility failed to provide a written notice of the bed-hold policy for 1 of 1 sample residents (#57) reviewed for facility-initiated transfers.

Inspectors wrote2. Interview with the DON on 10/13/22 at 9:54 AM revealed she expected staff to perform hand hygiene upon entering a resident room and before exiting the room. In addition, staff should prepare supplies prior to the start of care and should don clean gloves after coming in contact with soiled items, prior to touching clean items. Further interview revealed if she observed staff perform incontinence care and touch clean items prior to removing their soiled gloves, she would assign additional education for the staff member to complete. 3. Review of the policy titled Handwashing/Hand Hygiene dated 4/1/22 showed .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. [...]