32 Reports
Inspection Report — Mar 4, 2026
Complaint Investigation State
Date: Mar 4, 2026
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On-site complaint investigation of complaints 2785298 and 00159809 at a Nursing Care Institution, conducted 4 March 2026.
Complaint Details
The state complaint survey was conducted on March 4, 2026, through March 4, 2026, of the following complaint #s 2785298 and 00159809. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 20, 2026
Complaint Investigation State
Date: Feb 20, 2026
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On-site complaint investigation of complaints 00159543 and 00159604 at a Nursing Care Institution, conducted 20 February 2026.
Complaint Details
This complaint survey was conducted on February 20, 2026, with the investigation of complaints: 00159543 and 00159604. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 10, 2026
Complaint Investigation State
Date: Feb 10, 2026
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On-site complaint investigation of intake #00158334 at Mountain View Care Center, conducted 10 February 2026.
Complaint Details
An onsite complaint survey was conducted on February 10, 2026 for intake #00158334. Federal investigation of intake #2737011 found the facility in compliance with 42 CFR Part 483.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Dec 1, 2025
Complaint Investigation State
Date: Dec 1, 2025
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On-site complaint investigation of multiple complaints at a Nursing Care Institution, conducted 1 December 2025.
Complaint Details
A state only Risk Based Survey was conducted between October 28, 2025 through October 30, 2025. The following complaints were investigated, AZ00153582/2252233, AZ00162743/2252255, AZ00163262/2252147, AZ00164807/2252137AZ00167080/2252174, AZ00169261/2252158, AZ00173434/2252271, AZ00174107/225214, AZ00174652/2252279, AZ00175226/2252280, AZ00176188/2252284, AZ00176409/2252295, AZ00176470/2252288, AZ00176627/2252292, AZ00176736/2252293, AZ00177295/2252297, AZ00177680/2252299, AZ00179131/2252313, AZ00179493/2252314, AZ00179623/2252319, AZ00179636/2252323, AZ00180370/2252325, AZ00180433/2252291, AZ00181001/2252318, AZ00181367/2252228, AZ00181514/2252332, AZ00181651/2252330, AZ00181794/2252201, AZ00182128/2252335, AZ00182316/2252336, AZ00182610/2252339, AZ00182627/2252340, AZ00182887/2252343, AZ00182892/2252342.
Findings
The inspection found one deficiency related to failure to protect residents from abuse by other residents. A plan of correction was provided and accepted.
Deficiencies (1)
R9-10-410 — The facility failed to protect the rights of multiple residents to be free from abuse by other residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 10, 2025
State
Date: Jun 10, 2025
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On-site inspection of type Other at Mountain View Care Center, a Nursing Care Institution, conducted 10 June 2025.
Findings
The facility was found not to be in substantial compliance with emergency preparedness requirements under 42 CFR 483.73. Seven deficiencies were cited, all with plans of correction provided.
Deficiencies (7)
§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) — No evidence text was provided for this deficiency.
Multiple Occupancies - Construction Type — No evidence text was provided for this deficiency.
Means of Egress - General — No evidence text was provided for this deficiency.
Portable Fire Extinguishers — No evidence text was provided for this deficiency.
Corridor - Doors — No evidence text was provided for this deficiency.
Electrical Systems - Essential Electric System Maintenance and Testing — No evidence text was provided for this deficiency.
Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet — No evidence text was provided for this deficiency.
Report Facts
Deficiencies cited: 7
Inspection Report — Apr 28, 2025
Complaint Investigation State
Date: Apr 28, 2025
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On-site complaint investigation of intakes 00126202 and AZ00224188 at a Nursing Care Institution, conducted 24 April 2025 through 28 April 2025.
Complaint Details
An onsite complaint investigation was conducted on April 24, 2025 through April 28, 2025 for intake #00126202 and intake #AZ00224188. No deficiencies were cited.
Findings
No deficiencies were cited during this inspection.
Report Facts
Complaints investigated: 2
Inspection Report — Mar 17, 2025
Complaint Investigation State
Date: Mar 17, 2025
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On-site complaint investigation of intakes 00116398, 00115620, AZ00223590, and AZ00223530 at a Nursing Care Institution, conducted 17 March 2025.
Complaint Details
A complaint survey was conducted on March 17, 2025 for the investigation of intake #00116398, 00115620. Federal comments also noted investigation of intake #AZ00223590, AZ00223530. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 4
Inspection Report — Jan 27, 2025
Complaint Investigation State
Date: Jan 27, 2025
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On-site complaint investigation of intake numbers AZ00221881 and AZ00221875 at a Nursing Care Institution, conducted 27 January 2025.
Complaint Details
An onsite complaint survey was conducted on January 27, 2025 for the investigation of intake # AZ00221881 and intake # AZ00221875. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Dec 26, 2024
Complaint Investigation State
Date: Dec 26, 2024
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On-site complaint investigation of multiple complaints including AZ00217241, AZ00214402, AZ00214230, AZ00213951, AZ00212240, AZ00209872, AZ00209802, AZ00208550, AZ00208417, AZ00207100, and AZ00206681 at a Nursing Care Institution, conducted 24 through 26 December 2024.
Complaint Details
An onsite complaint survey was conducted on December 24 through December 26, 2024 for the investigation of intake # AZ00217241, AZ00214402, AZ00214230, AZ00213951, AZ00212240, AZ00209872, AZ00209802, AZ00208550, AZ00208417, AZ00207100, AZ00206681. There were no deficiencies cited. Federal comments also note an onsite complaint survey for intake # AZ00217239, AZ00214401, AZ00214229, AZ00213945, AZ00212239, AZ00209871, AZ00209802, AZ00208549, AZ00208415, AZ00207099, AZ00206681 with no deficiencies cited.
Findings
This inspection found no deficiencies.
Report Facts
Complaints investigated: 11
Inspection Report — Dec 20, 2024
Complaint Investigation State
Date: Dec 20, 2024
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On-site complaint investigation of intake numbers AZ00220182 and AZ00220181 at a Nursing Care Institution, conducted 20 December 2024.
Complaint Details
An onsite complaint survey was conducted on December 20, 2024 for the investigation of intake # AZ00220182 and intake # AZ00220181. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Nov 22, 2024
Complaint Investigation State
Date: Nov 22, 2024
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On-site complaint investigation of intakes AZ00206528, AZ00205480, AZ00218658, AZ00218840 and AZ00207447 at a Nursing Care Institution, conducted 22 November 2024.
Complaint Details
The onsite investigation of intake AZ00206528, AZ00205480, AZ00218658, AZ00218840 and AZ00207447 was conducted on November 22, 2024. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 5
Inspection Report — Nov 1, 2024
Complaint Investigation State
Date: Nov 1, 2024
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On-site complaint investigation of intake numbers AZ00217927, AZ00217831, and AZ00217926 at a Nursing Care Institution, conducted 28 October through 1 November 2024.
Complaint Details
A complaint survey was conducted on October 28 through November 1, 2024 for the investigation of intake #s: AZ00217927, AZ00217831, and AZ00217926. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Inspection Report — Aug 30, 2024
Complaint Investigation State
Date: Aug 30, 2024
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On-site complaint investigation of complaints AZ00214981 and AZ00214980 at a Nursing Care Institution, conducted 30 August 2024.
Complaint Details
The investigation of complaint AZ00214981 was conducted on August 30, 2024. The investigation of complaint AZ00214980 was conducted on August 30, 2024. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 19, 2024
Complaint Investigation State
Date: Jul 19, 2024
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On-site complaint investigation of intakes AZ00213137 and AZ00213242 at a Nursing Care Institution, conducted 19 July 2024.
Complaint Details
An onsite complaint survey was conducted on July 19, 2024 for the investigation of intake # AZ00213137, AZ00213242. There were no deficiencies cited. Federal comments also note investigation of intake # AZ00213137, AZ00213240 with no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jul 9, 2024
Complaint Investigation State
Date: Jul 9, 2024
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On-site complaint investigation of intake numbers AZ00212740 and AZ00212739 at a Nursing Care Institution, conducted 9 July 2024.
Complaint Details
An onsite complaint survey was conducted on July 9, 2024 for the investigation of intake # AZ00212740 and intake # AZ00212739. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Apr 29, 2024
Complaint Investigation State
Date: Apr 29, 2024
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On-site complaint investigation of complaints AZ00209587 and AZ00209588 at a Nursing Care Institution, conducted 29 April 2024.
Complaint Details
The Complaint survey was conducted on 4/29/24 with the investigation of the following complaints: AZ00209587 AZ00209588 The census was 102. There were no deficiencies cited
Findings
This inspection resulted in no deficiencies.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 24, 2024
Complaint Investigation State
Date: Apr 24, 2024
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On-site complaint investigation of intake AZ00209327 and AZ00209326 at a Nursing Care Institution, conducted 24 April 2024.
Complaint Details
An onsite complaint survey was conducted on April 24, 2023 for the investigation of intake #AZ00209327. An onsite complaint survey was conducted on April 24, 2023 for the investigation of intake #AZ00209326.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Apr 10, 2024
Complaint Investigation State
Date: Apr 10, 2024
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On-site complaint investigation of intake #AZ00208278 and #AZ00208276 at a Nursing Care Institution, conducted 10 April 2024.
Complaint Details
An onsite complaint survey was conducted on April 10, 2024 for the investigation of intake #AZ00208278 and intake #AZ00208276. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Jan 19, 2024
Complaint Investigation State
Date: Jan 19, 2024
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On-site complaint investigation conducted January 15 through January 19, 2024, for multiple complaint intake numbers at a Nursing Care Institution.
Complaint Details
A complaint survey was conducted January 15 through January 19, 2024 for the investigation of numerous intake numbers including AZ00176815, AZ00179102, AZ00179540, AZ00181425, AZ00182461, AZ00183342, AZ00183411, AZ00184056, AZ00184173, AZ00184225, AZ00184776, AZ00184899, AZ00184901, AZ00194914, AZ00184917, AZ00184919, AZ0184929, AZ00184922, AZ00185076, AZ00185065, AZ00185128, AZ00185381, AZ00187468, AZ00187461, AZ00187691, AZ00187728, AZ00189060, AZ00189278, AZ00189927, AZ00190092, AZ00190651, AZ00190685, AZ00191156, AZ00192880, AZ00193039, AZ00193296, AZ00193373, AZ00193599, AZ00194452, AZ00194530, AZ00197176, AZ00199070, AZ00201060, AZ00201333, AZ00201425, AZ00201511, AZ00202221, AZ00202402, AZ00203327, AZ00203400, AZ0204187, AZ00204443, AZ00205088, AZ00205109.
Findings
The inspection found six deficiencies related to failure to thoroughly investigate suspected abuse, failure to ensure residents were free from abuse, inadequate supervision leading to wandering and elopement risks, and failure to prevent resident-to-resident altercations. Plans of correction were provided for all deficiencies.
Deficiencies (6)
R9-10-403 — The facility failed to complete a thorough investigation to rule out abuse regarding an injury of unknown origin for one resident, including lack of interviews and family contact.
§483.12 — The facility failed to ensure one resident was free from abuse by a visitor and five residents were free from abuse by another resident, risking resident harm.
§483.12(c) — The facility failed to thoroughly investigate allegations of abuse regarding an injury of unknown origin for one resident, including lack of interviews and family contact.
§483.25(d) — The facility failed to provide adequate supervision to prevent a high-risk resident from elopement and wandering, resulting in the resident leaving the building unsupervised.
R9-10-410 — The facility failed to protect residents from abuse, evidenced by a resident-to-resident altercation resulting in injury to one resident.
R9-10-425 — The facility failed to provide adequate supervision to prevent residents from wandering into other residents' rooms and to prevent elopement, risking avoidable harm.
Report Facts
Deficiencies cited: 6
Inspection Report — Dec 13, 2023
Complaint Investigation State
Date: Dec 13, 2023
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On-site complaint investigation of multiple complaints including AZ00203941, AZ00203512, AZ00201530, AZ00201146, AZ00187924, AZ00203508, AZ00202106, AZ00198942 and AZ00187657 at a Nursing Care Institution, conducted 12 December 2023 through 13 December 2023.
Complaint Details
The complaint survey was conducted on 12/12/23 through 12/13/23 for the investigation of intake #s: AZ00203941, AZ00203512, AZ00201530, AZ00201146, AZ00187924, AZ00203508, AZ00202106, AZ00198942 and AZ00187657. There were no deficiencies cited. The complaint survey was conducted on 12/12/23 through 12/13/23 for the investigation of intake #s: AZ00203938, AZ00203511, AZ00201524, AZ00201145, AZ00187923, AZ00203508, AZ00202106, AZ00198942 and AZ00187657. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited or citations.
Inspection Report — Sep 8, 2023
Complaint Investigation State
Date: Sep 8, 2023
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On-site complaint investigation of complaints AZ00199169 and AZ00199168 at a Nursing Care Institution, conducted 8 September 2023.
Complaint Details
The investigation of complaint AZ00199169 was conducted on September 8, 2023. The investigation of complaint AZ00199168 was conducted on September 8, 2023. There were no deficiencies cited.
Findings
No deficiencies were cited during this inspection.
Inspection Report — Aug 28, 2023
Complaint Investigation State
Date: Aug 28, 2023
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On-site complaint investigation of complaints AZ00199169 and AZ00199168 at a Nursing Care Institution, conducted 28 August 2023.
Complaint Details
The investigation of complaint AZ00199169 and complaint AZ00199168 was conducted on August 28, 2023. The following deficiencies were cited.
Findings
The inspection found two deficiencies related to inadequate supervision and failure to implement fall prevention measures for a high-risk resident, resulting in multiple falls and injuries.
Deficiencies (2)
§483.25(d) — The facility failed to ensure adequate supervision and implementation of fall prevention measures for a resident at high risk for falls, resulting in multiple falls with injuries including bruises, lacerations, and hematoma.
R9-10-425 — The administrator failed to ensure the premises and equipment were free from conditions that could cause physical injury, as evidenced by inadequate supervision and failure to provide a recommended 1:1 sitter for a high fall-risk resident who sustained multiple injuries from falls.
Report Facts
Deficiencies cited: 2
Inspection Report — Jul 28, 2023
Complaint Investigation State
Date: Jul 28, 2023
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On-site complaint investigation of multiple complaints including AZ00172449, AZ00172452, AZ00174297, AZ00174299, AZ00174518, AZ00174521, AZ00174585, AZ00174588, AZ00175580, AZ00176488, AZ00176492, AZ00178288, AZ00178289, AZ00178621, AZ00178622, AZ00179009, AZ00179014, AZ00179611, AZ00179612, AZ00179628, AZ00179630, AZ00180882, AZ00180883, AZ00181936, AZ00181937, AZ00183852, AZ00183854, AZ00184703, AZ00184704, AZ00185358, AZ00185359, AZ00186451, AZ00186452, AZ00186455, AZ00186791, AZ00186801, AZ00186802, AZ00187015, AZ00187064, AZ00187065, AZ00187940, AZ00187941, AZ00187977, AZ00187978, AZ00188249, AZ00188250, AZ00188520, AZ00188521, AZ00188623, AZ00188667, AZ00188737, AZ00188738, AZ00189011, AZ00189046, AZ00189047, AZ00189067, AZ00189068, AZ00189230, AZ00189231, AZ00189682, AZ00189702, AZ00189703, AZ00189927, AZ00189958, AZ00189959, AZ00190846, AZ00190847, AZ00191173, AZ00191174, AZ00193391, AZ00193418, AZ00193419, AZ00194260, AZ00194263, AZ00195465, AZ00195516, AZ00195583, AZ00195669, AZ00195670, AZ00195700, AZ00195701, AZ00195983, AZ00196439, AZ00197075, and AZ00197077 at a Nursing Care Institution, conducted 24 through 28 July 2023.
Complaint Details
A complaint survey was conducted on July 24 through July 28, 2023 for the investigation of intake numbers including AZ00172449, AZ00172452, AZ00174297, AZ00174299, AZ00174518, AZ00174521, AZ00174585, AZ00174588, AZ00175580, AZ00176488, AZ00176492, AZ00178288, AZ00178289, AZ00178621, AZ00178622, AZ00179009, AZ00179014, AZ00179611, AZ00179612, AZ00179628, AZ00179630, AZ00180882, AZ00180883, AZ00181936, AZ00181937, AZ00183852, AZ00183854, AZ00184703, AZ00184704, AZ00185358, AZ00185359, AZ00186451, AZ00186452, AZ00186455, AZ00186791, AZ00186801, AZ00186802, AZ00187015, AZ00187064, AZ00187065, AZ00187940, AZ00187941, AZ00187977, AZ00187978, AZ00188249, AZ00188250, AZ00188520, AZ00188521, AZ00188623, AZ00188667, AZ00188737, AZ00188738, AZ00189011, AZ00189046, AZ00189047, AZ00189067, AZ00189068, AZ00189230, AZ00189231, AZ00189682, AZ00189702, AZ00189703, AZ00189927, AZ00189958, AZ00189959, AZ00190846, AZ00190847, AZ00191173, AZ00191174, AZ00193391, AZ00193418, AZ00193419, AZ00194260, AZ00194263, AZ00195465, AZ00195516, AZ00195583, AZ00195669, AZ00195670, AZ00195700, AZ00195701, AZ00195983, AZ00196439, AZ00197075, and AZ00197077.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Jun 14, 2023
Complaint Investigation State
Date: Jun 14, 2023
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On-site complaint investigation of intakes AZ00195207, AZ00195215, AZ00195209, and AZ00195206 at a Nursing Care Institution, conducted 13-14 June 2023.
Complaint Details
An onsite survey was conducted on June 13 through June 14, 2023 for the investigation of intake #s: AZ00195207 and AZ00195215. A complaint survey was conducted on June 13 through June 14, 2023 for the investigation of intake #s: AZ00195209 and AZ00195206. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 4
Inspection Report — Jun 9, 2023
Complaint Investigation CMS
Date: Jun 9, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to ensure timely PASARR Level II referral for a resident with mental illness, inadequate supervision to prevent medication accidents for three residents, failure to have a registered nurse on duty for at least eight hours daily, and improper food storage practices.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to timely submit a PASARR Level II referral for a resident with mental illness, failed to supervise residents adequately to prevent medication accidents, failed to have an RN on duty for required hours on specific days, and failed to store food properly.
Findings
The facility failed to ensure timely PASARR Level II referral for one resident with multiple mental illness diagnoses. It also failed to provide adequate supervision to prevent medication accidents for three residents, resulting in unauthorized medications being present at bedside without proper orders or assessments. Additionally, the facility did not have a registered nurse on duty for at least eight consecutive hours on two days in July 2022. Food safety standards were not met as refrigerated items were stored improperly in the pantry.
Deficiencies (4)
Failed to ensure a referral for a PASARR Level II determination was obtained timely for one resident (#58) with mental illness diagnoses.
Failed to ensure three residents (#65, #211, and #11) received adequate supervision to prevent medication accidents, including unauthorized medications at bedside without orders or assessments.
Failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, on July 2 and 3, 2022.
Failed to ensure food was stored in accordance with professional standards for food safety; refrigerated dressing cups were stored in the pantry.
Report Facts
Residents affected: 1
Residents affected: 3
Days without RN coverage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding PASARR Level II referral for resident #58 | |
| Certified Nursing Assistant (CNA) Staff #35 | Interviewed regarding medication supervision and medication removal practices | |
| Licensed Practical Nurse (LPN) Staff #67 | Interviewed regarding medication orders, assessments, and removal procedures | |
| Director of Nursing (DON) Staff #15 | Interviewed regarding medication policies and RN staffing requirements | |
| Staff #94 Administrator | Interviewed regarding RN staffing and food storage expectations | |
| Staff #60 Staffing Coordinator | Interviewed regarding RN staffing schedules | |
| Food Services Director (FSD) Staff #117 | Interviewed regarding food storage practices |
Inspection Report — Jun 9, 2023
State
Date: Jun 9, 2023
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On-site inspection of a Nursing Care Institution at Mountain View Care Center conducted 9 June 2023 as a routine Other inspection type.
Findings
Two deficiencies were found related to fire safety and electrical hazards. The facility failed to keep a rated door self-closing and improperly used extension cords and power strips, but plans of correction were provided.
Deficiencies (2)
Doors with Self-Closing Devices — The facility allowed a rated door to the kitchen to be held open with a clean plate rack, which could allow smoke and heat to spread during a fire.
R9-10-403.E — The facility failed to ensure proper use of extension cords and power strips, including a refrigerator plugged into a power strip and an extension cord used in a resident room, creating potential fire hazards.
Report Facts
Deficiencies cited: 2
Inspection Report — Jun 9, 2023
Annual Inspection State
Date: Jun 9, 2023
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On-site annual compliance inspection of a Nursing Care Institution at Mountain View Care Center conducted from June 5 through June 9, 2023.
Findings
The inspection identified five deficiencies related to PASARR Level II referral delays, inadequate supervision to prevent medication accidents, insufficient RN coverage, and improper food storage practices. Plans of correction were provided for all deficiencies.
Deficiencies (5)
§483.20(k) — The facility failed to ensure a timely referral for a PASARR Level II determination for one resident, risking inappropriate level of services and lack of psychological support.
§483.25(d) — The facility failed to ensure adequate supervision to prevent medication accidents for three residents, resulting in unauthorized medications being present at bedside.
§483.35(b) — The facility failed to provide registered nurse services for at least eight consecutive hours on July 2 and 3, 2022, as required.
§483.60(i) — The facility failed to store food according to professional food safety standards, as evidenced by unrefrigerated dressing cups in the pantry.
R9-10-423 — The facility failed to ensure proper storage, refrigeration, and reheating of food when contracting with a food establishment, demonstrated by unrefrigerated dressing cups.
Report Facts
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #41 | Social Services Director | Interviewed regarding PASARR Level II referral for resident #58. |
| Staff #35 | Certified Nursing Assistant | Interviewed about medication supervision and policy enforcement. |
| Staff #67 | Licensed Practical Nurse | Interviewed about medication orders and self-administration assessments. |
| Staff #15 | Director of Nursing | Interviewed about medication policies and risks of unauthorized medications. |
| Staff #60 | Staffing Coordinator | Interviewed about RN staffing on July 2 and 3, 2022. |
| Staff #94 | Administrator | Interviewed about RN staffing and food storage policies. |
| Staff #117 | Food Services Director | Interviewed about food storage practices. |
Inspection Report — Mar 24, 2023
Complaint Investigation CMS
Date: Mar 24, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to ensure informed consent for vaccinations, lack of physician orders for vaccine administration, and inadequate care related to an indwelling catheter for residents.
Complaint Details
The complaint investigation focused on informed consent for vaccinations for resident #2 and appropriate care for resident #5 with an indwelling catheter. The findings substantiated failures in obtaining informed consent, physician orders, and timely pain management.
Findings
The facility failed to ensure informed consent was obtained from resident #2 or her representative prior to vaccination, failed to obtain physician orders for vaccine administration, and failed to provide appropriate care and timely pain management for resident #5 with an indwelling catheter, resulting in resident pain and distress.
Deficiencies (3)
Failure to ensure resident #2 and/or her representative were informed of the risks and benefits of vaccinations prior to administration.
Failure to ensure a physician order for vaccinations was obtained prior to administration for resident #2.
Failure to provide appropriate care related to indwelling catheter for resident #5, including lack of timely pain assessment and management.
Report Facts
Pain scale: 7
Pain scale: 8
Foley catheter size: 18
Foley catheter balloon size: 5
Urine output: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #150 | Provider | Provided verbal consent for resident #2's vaccinations. |
| Staff #157 | Nurse Practitioner | Provided verbal consent for resident #2's vaccinations. |
| Staff #57 | Licensed Practical Nurse | Witnessed vaccination consent forms for resident #2. |
| Staff #117 | Licensed Practical Nurse | Witnessed vaccination consent forms for resident #2. |
| Staff #78 | Licensed Practical Nurse | Interviewed regarding vaccination consent and physician orders. |
| Staff #20 | Infection Preventionist | Responsible for vaccination program; interviewed about consent and physician orders. |
| Staff #101 | Director of Nursing | Interviewed regarding expectations for consent and physician orders. |
| Staff #37 | Registered Nurse | Cared for resident #5; failed to assess pain complaints timely. |
| Staff #60 | Licensed Practical Nurse | Assessed and discontinued Foley catheter for resident #5; failed to timely address pain complaints. |
| Staff #66 | Certified Nursing Assistant | Reported resident #5's pain complaints to nursing staff. |
| Staff #74 | Unit Manager | Followed up on resident #5's pain complaints and Foley catheter removal. |
Inspection Report — Mar 24, 2023
CMS
Date: Mar 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident informed consent for vaccinations, physician orders for vaccine administration, and appropriate care related to indwelling catheters.
Findings
The facility failed to ensure informed consent was properly obtained for vaccinations for one resident (#2), failed to obtain physician orders prior to vaccine administration, and failed to provide appropriate care and timely assessment for one resident (#5) with an indwelling catheter, resulting in resident pain and distress.
Deficiencies (3)
Failed to ensure resident or representative was informed of risks and benefits of vaccinations prior to administration.
Failed to ensure a physician order for vaccinations was obtained prior to administration.
Failed to provide appropriate care related to indwelling catheter, including lack of timely pain assessment and failure to obtain physician order for catheter removal.
Report Facts
Residents Affected: 1
Residents Affected: 1
Pain scale: 8
Pain scale: 7
Foley catheter size: 18
Foley balloon size: 5
Urine output volume: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #78 | Licensed Practical Nurse (LPN) | Interviewed regarding vaccination consent and physician order practices |
| Staff #20 | Infection Preventionist (IP) | Interviewed regarding vaccination program and consent procedures |
| Staff #101 | Director of Nursing (DON) | Interviewed regarding expectations for vaccination consent and physician orders |
| Staff #37 | Registered Nurse (RN) | Interviewed regarding resident #5 catheter pain complaints and care |
| Staff #66 | Certified Nursing Assistant (CNA) | Interviewed regarding resident #5 pain complaints and communication with nursing staff |
| Staff #60 | Licensed Practical Nurse (LPN) | Interviewed regarding care and assessment of resident #5 catheter pain |
| Staff #74 | Unit Manager | Interviewed regarding follow-up on resident #5 catheter pain and care |
Inspection Report — May 18, 2022
Routine CMS
Date: May 18, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, medication administration, mental health referrals, medication quality, pain management, staffing adequacy, medication error rates, and food safety standards.
Findings
The facility was found deficient in maintaining resident dignity, ensuring safe medication administration, completing required mental health referrals, providing professional quality medication services, managing pain appropriately, maintaining adequate staffing levels, keeping medication error rates below 5%, and ensuring proper food safety and kitchen sanitation practices.
Deficiencies (8)
Failed to maintain dignity for a resident by not providing proper grooming and shaving facial hair as needed.
Failed to ensure unsupervised medications were not left on a resident's bedside table without assessment for safe self-administration.
Failed to refer two residents with serious mental illness to the appropriate State-designated mental health authority for review.
Failed to ensure medication services met professional standards, including proper administration and documentation of refusals.
Failed to provide safe and appropriate pain management by delaying administration of prescribed opioid medication.
Failed to provide sufficient nursing staff to meet resident needs, resulting in unmet care needs such as delayed incontinence care and missed showers.
Failed to ensure medication error rate was below 5%, including failure to offer medication daily and administering incorrect medication form.
Failed to consistently monitor refrigerator/freezer temperatures and maintain kitchen equipment cleanliness according to food safety standards.
Report Facts
Medication error rate: 6.67
Medication refusals: 10
Medication not administered: 4
Required nursing hours per 24-hour period: 230
Days understaffed in April 2022: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #200 | Director of Nursing | Interviewed regarding expectations for dignity, medication administration, PASARR referrals, pain management, and staffing. |
| Staff #210 | Licensed Practical Nurse | Observed administering medications and interviewed regarding medication refusals. |
| Staff #11 | Staffing Coordinator | Interviewed regarding staffing levels and challenges. |
| Staff #52 | Kitchen Manager | Interviewed regarding refrigerator/freezer temperature logs and kitchen cleanliness. |
| Staff #20 | Registered Nurse | Observed administering medication and interviewed regarding medication administration procedures. |
Inspection Report — Feb 3, 2020
Annual Inspection CMS
Date: Feb 3, 2020
Visit Reason
The inspection was conducted as part of a standard annual survey to assess compliance with regulatory requirements, including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, inadequate pressure ulcer care and treatment, incomplete care plans, medication errors, improper medication storage, and insufficient staff competency for wound care. The facility also failed to monitor dialysis care appropriately and did not maintain proper infection control during medication administration.
Deficiencies (9)
Failure to ensure residents were treated with dignity and respect, including inappropriate clothing and exposure.
Inadequate oversight and treatment of pressure ulcers for multiple residents, including delayed assessments, lack of physician notification, and missed treatments.
Failure to develop baseline and comprehensive care plans for residents' specific needs such as dialysis, urinary incontinence, and skin integrity.
Medication administration error involving Risperdal Consta not warmed per manufacturer's instructions, requiring close monitoring for adverse effects.
Failure to monitor and document AV shunt site assessments for dialysis resident on multiple days, and delayed initiation of dialysis care plan and physician orders.
Failure to store medications at proper temperatures in medication refrigerators, with multiple days of temperatures below recommended range and unsecured narcotic box.
Failure to ensure staff competency for wound care, with wound nurse lacking certification and insufficient evaluation of wound care skills.
Failure to administer narcotic pain medication within ordered parameters, resulting in administration outside prescribed pain levels.
Failure to follow infection control procedures during medication administration, including handling medication capsules with bare hands.
Report Facts
Days with medication refrigerator temperatures out of range: 13
Days with medication refrigerator temperatures out of range: 20
Days with medication refrigerator temperatures out of range: 7
Days with medication refrigerator temperatures out of range: 18
Days with medication refrigerator temperatures out of range: 16
Days with medication refrigerator temperatures out of range: 23
Days with medication refrigerator temperatures out of range: 22
Days with medication refrigerator temperatures out of range: 20
Days with medication refrigerator temperatures out of range: 21
Days with medication refrigerator temperatures out of range: 19
Missed wound treatments: 12
Missed wound treatments: 8
Missed wound treatments: 2
Missed wound treatments: 2
Missed wound treatments: 3
Missed wound treatments: 3
Missed wound treatments: 8
Missed wound treatments: 2
Missed wound treatments: 2
Missed wound treatments: 3
Missed wound treatments: 7
Missed wound treatments: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #35 | Licensed Practical Nurse / Wound Nurse | Named in relation to wound care deficiencies and lack of certification |
| Staff #82 | Licensed Practical Nurse | Named in relation to medication administration error with Risperdal Consta |
| Staff #132 | Director of Nursing | Named in relation to oversight of wound care and medication administration |
| Staff #141 | Wound Nurse Practitioner | Named in relation to wound care consults and assessments |
| Staff #133 | Administrator | Named in relation to facility administration and response to medication storage issues |
| Staff #29 | MDS Coordinator | Named in relation to care plan and assessment delays |
| Staff #67 | Licensed Practical Nurse | Named in relation to medication refrigerator temperature monitoring |
| Staff #75 | Licensed Practical Nurse | Named in relation to infection control breach during medication administration |
Inspection Report — Feb 3, 2020
Re-Inspection CMS
Date: Feb 3, 2020
Visit Reason
The inspection was conducted to investigate concerns related to resident dignity, pressure ulcer care, medication administration, bladder incontinence care, wound care, medication storage, and staff competency.
Findings
The facility failed to ensure residents were treated with dignity and respect, failed to provide adequate pressure ulcer care including timely assessments and treatments, failed to develop appropriate care plans for dialysis and bladder incontinence, failed to administer medication per manufacturer instructions, failed to maintain medication storage temperatures within recommended ranges, and failed to ensure staff competency for wound care. The facility also failed to properly monitor and document dialysis access site assessments and failed to maintain secure storage for controlled medications.
Deficiencies (15)
Failure to ensure residents were treated with dignity and respect, including residents wearing hospital gowns for extended periods and residents being exposed in their rooms.
Failure to provide oversight of pressure ulcer program resulting in neglect and inadequate care for residents with pressure ulcers.
Failure to develop baseline care plan for dialysis within 48 hours of admission.
Failure to develop care plans for urinary incontinence, skin integrity, and dialysis needs.
Failure to administer Risperdal Consta per manufacturer's instructions, resulting in medication error and need for monitoring.
Failure to provide consistent skin assessments and treatments for resident with multiple skin issues including abrasions, open areas, wounds, and skin tears.
Failure to provide appropriate pressure ulcer care including timely assessments, physician notification, treatment orders, and treatment implementation for multiple residents with pressure ulcers.
Failure to provide timely assessments to determine potential for bladder retraining for resident with urinary incontinence.
Failure to provide safe and appropriate dialysis care including monitoring AV shunt site for bruit, thrill, bleeding, and infection signs on all days.
Failure to administer narcotic pain medication as ordered, including administering morphine outside ordered pain level parameters without physician notification.
Failure to store medications at proper temperatures per manufacturer recommendations and facility policy, including multiple refrigerators with temperatures below recommended range and unsecured narcotic box.
Failure to ensure wound nurse had appropriate competencies and certification to provide wound care and pressure ulcer treatment.
Failure of facility administration to identify and implement corrective actions for medication storage temperature issues and pressure ulcer care deficiencies.
Failure of quality assessment and assurance committee to identify and correct quality deficiencies related to medication storage and pressure ulcer care.
Failure to follow infection control procedures during medication administration, including handling medication with bare hands.
Report Facts
Missed wound treatments: 12
Medication refrigerator temperature out of range days: 19
Pressure ulcer measurements: 9.5
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1
Pressure ulcer measurements: 12
Pressure ulcer measurements: 0.9
Skin tear measurements: 0.5
Medication refrigerator temperature: 22
Medication refrigerator temperature: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #35 | Licensed Practical Nurse / Wound Nurse | Named in relation to wound care deficiencies and lack of wound nurse certification. |
| Staff #132 | Director of Nursing | Named in relation to oversight failures and interviews regarding wound care and medication errors. |
| Staff #141 | Wound Nurse Practitioner | Named in relation to wound care assessments and consultations. |
| Staff #82 | Licensed Practical Nurse | Named in relation to medication administration error with Risperdal Consta. |
| Staff #67 | Licensed Practical Nurse | Named in relation to medication refrigerator temperature monitoring. |
| Staff #29 | MDS Coordinator | Named in relation to care plan and assessment delays. |
| Staff #133 | Administrator | Named in relation to facility administration and quality assurance interviews. |
| Staff #75 | Licensed Practical Nurse | Named in relation to infection control breach during medication administration. |
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