Inspection Reports for
Mountain View Care Center

Complaint survey conducted with multiple deficiencies cited related to abuse investigations, accident hazards, resident supervision, and premises safety.

The visit was complaint-related, triggered by multiple reports of resident-to-resident abuse, injury of unknown origin, and inadequate supervision leading to wandering and elopement. The facility was found to have failed in protecting residents from abuse and in conducting thorough investigations.

The facility failed to protect residents from abuse by other residents and visitors, failed to prevent injuries of unknown origin, and did not provide adequate supervision to prevent wandering and elopement. Investigations into alleged abuse were incomplete, lacking interviews and family contact. Several residents experienced physical altercations resulting in injuries, and one resident eloped from the facility.

Complaint investigation conducted with deficiencies cited related to accident hazards and premises safety.

The complaint investigation revealed that resident #8 had multiple falls between 7/26/2023 and 8/6/2023, sustaining bruises, skin tears, lacerations, and a hematoma. Despite recommendations for a 1:1 sitter, the facility did not provide one. The resident was transferred to the hospital after the last fall. The investigation included interviews with staff and the Director of Nursing, confirming failure to follow physician recommendations and inadequate supervision.

The facility failed to ensure adequate supervision and implement recommended fall prevention measures for resident #8, who experienced multiple falls resulting in bruises, lacerations, and hospital transfers. Despite recommendations for a 1:1 sitter, no evidence was found that this was provided. The care plan was not revised to include new interventions despite repeated falls.

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.

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.

Recertification survey for Medicare Life Safety Code 2012 conducted; deficiencies cited related to doors with self-closing devices and electrical equipment safety; facility meets standards based on plan of correction.

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.

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.

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.