Mountainview Nursing Home

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to revise a comprehensive person-centered care plan to reflect the Resident's (R)1 current fall interventions for 1 of 3 sampled residents reviewed for falls.

Inspectors wroteBased on observation, interview, record review, and review of manufacturer guidelines, the facility failed to ensure a sheet was not applied in a manner that flattened the perimeter defined mattress cover which created the potential for accidents for 1 (Resident (R)1) of 3 sampled residents reviewed for falls.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Resident (R)1 received adequate supervision to prevent an elopement on 11/01/25 at approximately 6:00 AM. Specifically, R1 was located by staff outside the facility lying on the ground. R1 was dressed in bedtime clothing (pajamas and slippers). According to weather reports on 11/01/25 at 5:55 AM, the weather was 36 Degrees Fahrenheit (F). On 11/07/25 at 1:34 PM, the survey team provided the Administrator and Assistant Administrator with a copy of the CMS IJ Template and informed the facility IJ existed as of 11/01/25. The IJ was related to 483.24 Quality of Care. On 11/07/25 at 4:12 PM, the facility provided an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to follow infection control guidelines during an medication administration observation for two of seven resident observations (Resident (R) 13 and R19), during an observation of PPE (Personal Protective Equipment) for one of three COVID-19 positive residents (R24), and during a dressing change for one of one resident observation (R74) of 24 sample resident. These failures had the potential for spreading infections including COVID 19 to the vulnerable population in the facility.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure two of two residents (R) 18 and R85 of three reviewed for abuse was free from resident to resident physical and verbal abuse out of a total sample of 24 residents. This had the potential for the residents to sustain injuries from the altercation.

Inspectors wroteBased on record review and interview, the facility failed to ensure a written copy of the baseline care plan was provided to the resident and/or responsible party (RP) within 48 hours for one of one resident (Resident (R) 261) reviewed for baseline care plans. This failure had the potential for residents and/or RP not to be informed of the plan of care.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to develop a care plan for refusal of medications and meals for one (Resident (R)92) and failed to develop and implement a care plan for pressure ulcers for one of 24 sample residents R78. This failure had the potential for residents to have unmet care plan needs.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the care plan was revised to reflect an updated advanced directive status for one of one resident (Resident (R)92) reviewed for advanced directives. This failure had the potential for residents to have unmet care plan needs.

Inspectors wroteBased on record review and interview, the facility failed to have collaboration of care with the dialysis center for one of one resident (Resident (R)38) reviewed for dialysis. This failure had the potential to put R38 at risk for lack of communication between the facility and the dialysis center.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure risk and benefits were explained to the resident and/or representative (RP) prior to the use of psychotropic medications and failed to ensure targeted behaviors and side effects were monitored for administered psychotropics for one of five residents (Resident (R)46) reviewed for unnecessary medications. This failure had the potential for excessive psychotropic administration and for the residents and/or representative not to be able to make an informed decision regarding the use of the psychotropic medications.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to accurately check the insulin pen that was being used to administer insulin to one of one resident (Resident (R)14) administered insulin out of seven residents being observed during the medication administration task. This failure had the potential for bloodborne pathogens to infect residents by using a reusable insulin pen to a resident other than the resident that it had been ordered for.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have a permanently affixed compartment to store narcotics in the medication refrigerator on two of three units (North and [NAME] Units) which involved three of five residents (Resident (R) 259, R2, and R11) reviewed for medication storage of 24 sample residents This failure had the potential for these medications to be diverted.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure food items stored in 1 of 1 walk in refrigerator were properly labeled and dated to prevent the risk of food borne illness. Findings Include: Review of the facility policy titled, Food Purchasing and Inspection of Food Deliveries dated 2020 revealed Guidelines: All food items will be purchased from approved vendors and received according to the following guidelines. Procedure: 4 Inspect all deliveries carefully. Check for appropriate labeling, temperature, appearance, texture, odor, and other factors important for food safety. 6. Any unsafe food items will be refused or discarded immediately, and proper credit received per vendor policy. Review of the facility policy titled, Food Safety with an effective date of February 1, 2015, revealed Purpose: [...]

Inspectors wroteBased on observation, interview, and facility policy, the facility failed to ensure an effective pest control program for the environment to remain free from pests in 2 of 3 units observed for pests.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a clean and clutter free environment in rooms [ROOM NUMBERS]. Review of 1 of 3 units observed for environment.

Inspectors wroteBased on record reviews, interviews and review of the facility policy titled, Bed Hold and Return, the facility failed to ensure the resident or the resident's representative for Resident (R)91 and R43 received the bed hold and return policy upon transfer to the hospital or within a practicable amount of time after discharge to the hospital for 2 of 4 residents reviewed for hospitalization.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure an OBRA assessment for Resident (R)5 was completed, accurate and transmitted timely for 1 of 1 residents reviewed for a Missing OBRA assessment.

Inspectors wroteBased on record reviews, interviews, and review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility failed to ensure the MDS was complete and accurate for Resident (R)78. Specifically, Section G was not coded for 2 person assist with bed mobility, dressing, eating, toilet use, personal hygiene and bathing resulting in a fall with a major injury for 1 of 3 residents reviewed for falls with major injury.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to ensure a Preadmission Screen and Resident Review (PASARR) Level II was completed for 1 of 3 residents reviewed for PASARR. Specifically, Resident (R)4 did not have a PASARR Level II completed after a diagnosis of Mental Illness (MI). Findings Include: Review of an undated facility policy titled, Pre-admission Screening Policy (PASAR), revealed, Residents admitted to Mountainview Nursing Home will have a pre-admission screening completed prior to admission to assess for the need for special services and to assure placement is appropriate. If there are no indicators when the level I assessment is completed, resident will be accepted for admission. If resident does have indicators of a need for further services, then a Level II assessment must be completed by the appropriate agency. [...]

Inspectors wroteBased on record reviews, interviews, and review of the facility policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to formulate and implement a comprehensive plan of care for Resident (R)78, which included 2 person assist with all activities of daily living. The facility additionally failed to formulate and implement a comprehensive plan of care for R32 for seizures, convulsions and epilepsy for 2 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on review of the facility policy, observation, interview, and record review, the facility failed to continue orders for floating heels while in bed for Resident (R)43 for 5 of 6 days during the Recertification survey for1 of 1 reviewed for quality of care.

Inspectors wroteBased on review of the facility policy titled, Suprapubic Catheter Care, record reviews, observations, and interviews, the facility failed to follow a procedure during suprapubic catheter care for Resident (R)22 to prevent infection of the urinary tract for 1 of 1 residents reviewed for catheter care.

Inspectors wroteBased on review of facility policy, observation, record review, and interview, the facility failed to ensure proper storage and maintenance of Resident (R)84's nebulizer equipment, for 1 of 3 residents reviewed for respiratory therapy.

Inspectors wroteBased on record reviews, interviews, and review of the facility policy titled, Unnecessary Medications Use and Monitoring, the facility failed to ensure Resident (R)32 and R65 were free from unnecessary medications for 2 of 5 residents reviewed for Unnecessary Medications.

Inspectors wroteBased on review of the facility policy titled, Unnecessary Medications Use and Monitoring, record review, and interviews, the facility failed to ensure Resident (R)32 was free from an, as needed, basis psychotropic medication and further failed to ensure a required, gradual dose reduction (GDR), was attempted for R78, who is currently prescribed an antipsychotic with the diagnosis of dementia with behaviors.

Inspectors wroteBased on record reviews, interviews, and review of facility policy, the facility failed to provide or obtain laboratory services to meet the needs of Resident (R)65 for 1 of 1 residents reviewed.

Inspectors wroteBased on observation, interview, and review of the facility policy, the facility failed to ensure the resident call system was in working condition for 1 of 3 units observed for call light function. and failed to implement a procedure while call light system was inoperable.

Inspectors wroteBased on record review, interview and facility policy, the facility failed to use the required CMS 10055 form to notify 3 of 3 residents of their Skilled Nursing Facility Advanced Beneficiary Notice (ABN) of Non-coverage.

Inspectors wroteBased on review of the facility policy, documentation review, and interview, the faciltiy failed to post daily staffing for mutiple shifts as required by federal regulation.