Mountain Villa Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for two residents (Residents #5, and #8) of seven residents reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident #5 to address residents' blood thinner medication prescription, Eliquis. The facility failed to have a comprehensive person-centered care plan for Resident #8 to address residents' diabetes diagnosis. These failures could affect residents and put them at risk for not receiving care and services to meet their needs. Findings Include:Resident #5 Record review of Resident # 5's admission record dated 12/04/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 1 of 6 facility staff (LVN C) reviewed for trainings consistent with their expected roles, in that; -The facility failed to provide LVN C with training consistent with their expected roles. This failure could place residents at risk of accidents with potential harm due to staff not having up to date training.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident; and failed to have an established system in place for accurate reconciliation of all controlled drugs for 1 (East wing) of 2 medication carts that had residents with orders for controlled substances. The facility failed to ensure Licensed staff signed the form after counting and verifying that all controlled substances in the East Wing medication cart had been accounted for with the on-coming and off-going nurses on 12/03/25. This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for one (medication aide's medication cart) of two medications carts reviewed. The Medication Aide B failed to ensure to update label Resident #31's medication Sertraline 100 MG on 12/03/25 with the current dosage instructions to Give 1 tablet by mouth one time a day, to give 25 MG tablet for total dose of 125 MG.This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications. Record review of Resident #31's face sheet dated 12/03/25, revealed a [AGE] year-old male with an admission date 02/18/2022. [...]

Inspectors wroteBased on, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans. -The facility failed to ensure Resident #1 's pacemaker was addressed on her care plan. This failure placed the resident at risk for not having their individual needs met in a timely manner and could result in injury and a decline in physical well-being.

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 3 (CNA A) staff reviewed for EMR. The facility did not have CNA A's EMR on file upon hire. This failure could place residents at risk of abuse, neglect, and misappropriation of property.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #3 and Resident #32) reviewed for respect and dignity. The facility failed to ensure staff treated Resident #3 and Resident #32 with respect and dignity, with staff removing residents' trays prior to being completed. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on interviews and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #2, Resident #27, Resident #28, and Resident #36) of 13 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #2's comprehensive care plan addressed Resident's code status and fall mat. The facility failed to ensure Resident #27's comprehensive care plan addressed Resident #27's code status and PASRR services. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 5 (04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; 06/08/2024) of 91 days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 04/13/2024; 05/11/2024; 05/12/2024; 05/25/2024; and 06/08/2024. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 2 of 6 residents (Resident #28 & Resident #198) reviewed for medication errors. 1. The facility failed to ensure MA administered the correct dose of calcium and vitamin D to Resident #28 according to the physician orders. 2. The facility failed to ensure MA administered olmesartan medoxomil (for blood pressure) and amlodipine besylate (for blood pressure) to Resident #198 according to physician orders. These failures could place residents at risk of inadequate therapeutic outcomes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the menu was followed for 3 of 6 (Resident #2, Resident #25, and Resident #33) residents who received a pureed meal reviewed during the lunch meals served reviewed for food and nutrition services. The facility failed to ensure residents, receiving a puree texture diet, were provided the food according to the menu, included a dinner roll on 09/10/2024 and a dinner roll and ice cream on 09/11/2024. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance, and/or weight loss.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled. The facility failed to ensure that persons serving food handled food properly. These failures could place residents at risk for food borne illnesses and cross-contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (CNA B and LVN D) of 4 staff observed for infection control practices. 1. The facility failed to ensure CNA B removed gloves and performed hand hygiene at the appropriate time while providing resident incontinent care. 2. The facility failed to ensure LVN D sanitized hands at appropriate times when changing gloves during wound care. 3. The facility failed to ensure LVN D sanitized rubber tip of insulin flex pen prior to applying needle to insulin flex pen during administration of insulin to resident. These failures place residents at risk for unnecessary infections while in facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accommodate residents needs and preferences and accommodation of needs, for 1 (Resident #2) of 13 residents reviewed for dignity. The facility failed to ensure Resident #2's call light was within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 2 (Resident #46 and Resident #198) of 13 residents reviewed for care plan completion. 1. The facility failed to complete Resident #46 and Resident #198's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on interview, and record review, the facility failed to implement its written polices, and procedures that prohibit abuse, neglect and exploitation for 10 of 16 staff (Dietary Supervisor, Activities Director, CNA D, CNA E, CNA F, Nurse Aide G, CNA H, CMA K, CMA L, and [NAME] B) reviewed for neglect and abuse policies . The facility failed to conduct annual EMR/NAR screening for staff. This failure could put residents at risk of receiving services from employees who with a history of misconduct and/or were ineligible to provide services in this setting.

Inspectors wroteBased on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards for 1 (Resident #9) of 20 residents and to ensure 7 of 10 facility rooms were safe from hazards reviewed for accident hazards. 1. The facility failed to ensure that 5 resident-use bathroom sinks had hot water temperatures below 110 degrees F and did not put residents at risk of injury. 2. The facility failed to make sure the Resident #9's fall mat was placed according to plan of care 3. The facility failed to ensure that 1 utility closet and 1 housekeeping storage room remained closed/locked due to chemicals being stored in the housekeeping room and industry equipment/pipes in the utilizes closet. These failures could place residents at risk of injury.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation/storage, in that: 1. Foods in dry store, walk in, and freezer were not dated or labeled properly. 2. Food containers and food bags were not properly sealed in the kitchen and walk-in. 3. Hot food had been placed in the refrigerator while hot. 4. A dented can was not removed from shelf rotation. 5. the dish washer temperature was not at or above 140 degrees. These failures could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #30) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #9's that reflected as needed oxygen therapy. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 10 residents (Resident #9) reviewed for enteral feeding. Resident #9 was on continuous feeding and while feeding. The facility failed to ensure Resident #9's head of the bed was elevated at a 45-degree angle per care plan These failures could place residents receiving enteral feedings at risk of aspiration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #30) of 4 residents observed for oxygen management. Resident #30 was on oxygen which did not have an oxygen sign posted outside of her bedroom. Resident #30 was outside in the front patio of the facility with an oxygen tank that was in the red indicating refill oxygen. These failures could place residents on oxygen therapy at risk of an explosion or fire, injury, incorrect or inadequate oxygen support, and decline in health.

Inspectors wroteBased on the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 1 of 1 (Dumpster) garbage dumpster containers reviewed for food safety requirements. 1. One dumpster in the back alley of the facility had trash on the floor outside and around the dumpsters. 2. One dumpster had its lid open. This failure could affect residents by placing them at risk of food borne illness, illnesses, or be provided an unsafe, unsanitary and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to post required nurse staffing information in a prominent place readily accessible to resident and visitors The Facility failed to ensure nurse staffing information was posted. This failure could put staff, residents, and resident representatives at risk of being unaware of actual staffing levels and available staff.