Inspection Reports for
Mountain View Post Acute
835 TENDERFOOT HILL RD, COLORADO SPRINGS, CO, 80906-
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
15.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
196% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
78% occupied
Based on a September 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 11, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident safety, abuse prevention, infection control, and maintaining a homelike environment.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, protecting residents from physical abuse, and implementing an effective infection prevention and control program. Specific issues included broken towel racks, unclean resident rooms, physical altercations between residents, and housekeeping staff failing to follow proper cleaning and hand hygiene procedures.
Deficiencies (3)
Failed to maintain a comfortable and homelike environment including broken towel racks, broken window seals, unclean rooms, and broken shower room lights.
Failed to protect residents from physical abuse, specifically a substantiated physical altercation between two residents resulting in a skin tear.
Failed to provide and implement an infection prevention and control program, including improper cleaning procedures and failure to perform hand hygiene and glove changes appropriately.
Report Facts
Towel racks ordered: 45
Residents in sample: 53
Residents involved in abuse incident: 2
Duration of safety checks: 72
Observation duration: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nurse Aide | Interviewed regarding responsibility for ensuring residents' rooms were clean and stocked with towels. |
| Maintenance Director | Maintenance Director | Interviewed about broken towel racks and maintenance audits. |
| ADON | Assistant Director of Nursing | Interviewed about nursing staff responsibilities and post-incident measures. |
| CNA #9 | Certified Nurse Aide | Witnessed physical altercation between residents #111 and #66. |
| CNA #2 | Certified Nurse Aide | Interviewed about resident behaviors and staff monitoring. |
| CNA #1 | Certified Nurse Aide | Interviewed about resident behaviors and staff supervision. |
| LPN #5 | Licensed Practical Nurse | Interviewed about resident behaviors and monitoring. |
| RN #3 | Registered Nurse | Interviewed about assessment after resident altercation. |
| NHA | Nursing Home Administrator | Provided facility policies and concluded substantiation of abuse incident. |
| HK #1 | Housekeeper | Observed failing to perform hand hygiene and proper cleaning procedures. |
| HK #2 | Housekeeper | Observed failing to perform hand hygiene and proper cleaning procedures. |
| Infection Preventionist | Infection Preventionist | Interviewed about proper hand hygiene and cleaning protocols. |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 16, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration and call light system functionality at Mountain View Post Acute nursing home.
Findings
The facility failed to ensure timely administration of medications to Resident #6, with multiple late doses documented, and failed to maintain a fully functional call light system, resulting in delayed staff response to resident calls for assistance.
Deficiencies (2)
Failure to ensure Resident #6 received medications in a timely manner as prescribed, with multiple late medication administrations documented.
Failure to ensure the call light system was functioning properly, resulting in staff being unable to hear call light alerts away from the centralized staff work area and delayed response times.
Report Facts
Late medication administrations: 102
Late Baclofen administrations: 16
Late Eliquis administrations: 9
Late Gabapentin administrations: 9
Medication doses late on 4/7/25: 12
Call light response time range: 102
Call light response time range: 25
Resident grievances: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration audit as responsible for 87 late medication events |
| Staff Development Coordinator | SDC | Interviewed regarding medication cart assignments and medication administration challenges |
| Unit Manager | UM | Interviewed about medication administration timing and cart assignments |
| Assistant Director of Nursing | ADON | Interviewed about medication ordering changes and administration windows |
| Director of Nursing | DON | Interviewed about medication administration schedule and audit results |
| Nursing Home Administrator | NHA | Interviewed about call light system issues and response expectations |
| Certified Nurse Aide #3 | CNA | Interviewed about call light system audibility and visibility issues |
| Licensed Practical Nurse #1 | LPN | Interviewed about call light system limitations and visibility |
| Certified Nurse Aide #1 | CNA | Interviewed about call light system audibility and visibility challenges |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and services to a resident diagnosed with a mental disorder or psychosocial adjustment difficulty.
Complaint Details
The complaint investigation focused on Resident #2's care related to mental health and psychosocial needs. The facility was found deficient in providing adequate psychosocial support, behavioral health referrals, and proper monitoring of psychoactive medications. The resident exhibited escalating behaviors, including delusions, paranoia, aggression, and attempts to leave the facility, which were not adequately managed or documented.
Findings
The facility failed to ensure that Resident #2, diagnosed with multiple mental health conditions and a history of trauma, received appropriate individualized care, psychosocial support, and monitoring. Despite escalating behaviors and traumatic history, the resident was not reviewed in psychoactive drug meetings nor referred for behavioral health counseling, and interventions were inconsistently documented.
Deficiencies (1)
Failure to provide appropriate treatment and services to a resident with mental disorder or psychosocial adjustment difficulty.
Report Facts
Residents Affected: 3
Medication doses missed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Interviewed regarding Resident #2's behaviors and interventions. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #2's agitation and staff interventions. |
| SSD | Social Services Director | Interviewed about psychoactive drug meetings and behavioral health referrals. |
| SSDMC | Social Services Director for Memory Care Unit | Interviewed about Resident #2's behaviors and interventions. |
| NHA | Nursing Home Administrator | Interviewed about facility placement decisions and behavioral health support. |
Inspection Report
Routine
Deficiencies: 5
Date: Sep 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and pharmaceutical services at Mountain View Post Acute nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide timely incontinence care to Resident #11, failure to follow physician orders for skin and wound care for Residents #2 and #12, failure to administer medication as ordered for Resident #7, failure to maintain proper controlled substance records, and failure to follow infection control procedures for residents on enhanced barrier precautions.
Deficiencies (5)
Failure to provide timely incontinence care for Resident #11.
Failure to ensure physician's orders for skin and wound care were followed for Residents #2 and #12.
Failure to ensure Resident #7 received medication as ordered by the physician.
Failure to maintain a system of controlled substance records for discontinued controlled substances.
Failure to ensure nursing staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP).
Report Facts
Residents reviewed: 25
Residents affected: 3
Residents affected: 1
Residents affected: 1
Medication doses missed: 5
Date of survey completion: Sep 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Aide | Named in incontinence care deficiency for Resident #11 and infection control deficiency for Resident #25 |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding incontinence care and medication administration issues |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration and infection control |
| RN #1 | Registered Nurse | Interviewed regarding incontinence care and medication administration |
| RN #2 | Registered Nurse | Interviewed regarding medication administration and infection control |
| RN #3 | Registered Nurse | Interviewed regarding wound care documentation |
| CNA #1 | Certified Nursing Aide | Interviewed regarding infection control practices |
| CNA #3 | Certified Nursing Aide | Interviewed regarding infection control practices |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incontinence care, medication administration, and controlled substance management |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding controlled substance management |
| Regional Director of Clinical Services | Regional Director of Clinical Services (RDCS) | Interviewed regarding wound care documentation |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control program and staff compliance |
Inspection Report
Deficiencies: 1
Date: Feb 5, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of care following concerns about the monitoring of Resident #1 after a suspected illicit drug use and change of condition.
Findings
The facility failed to adequately monitor Resident #1 who had elevated blood pressure and pulse following suspected illicit drug use. Despite orders for assessments and monitoring over 72 hours, there was no documented follow-up or vital signs after 2/2/24, and the resident refused some assessments without proper documentation. Staff interviews confirmed lapses in monitoring and documentation.
Deficiencies (1)
Failure to monitor Resident #1 with a change of condition after suspected illicit drug use according to professional standards.
Report Facts
Elevated blood pressure readings: 176
Elevated pulse readings: 131
Baseline pulse range: 72
Baseline blood pressure range: 98
Monitoring period: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #1 | Licensed Practical Nurse | Interviewed regarding monitoring requirements and difficulties with EMR system |
| Interim director of nursing | Interim Director of Nursing | Interviewed about failure to monitor Resident #1 and lack of documentation |
| Registered nurse #1 | Registered Nurse | Interviewed about vital sign monitoring frequency and assessment requirements |
Inspection Report
Routine
Deficiencies: 20
Date: Nov 16, 2023
Visit Reason
Routine state survey inspection of Mountain View Post Acute nursing home to assess compliance with federal and state regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and timely response to call lights, resident rights and preferences, environmental maintenance, abuse prevention and investigation, MDS assessment and transmission, activities programming, pressure ulcer care, fall prevention, nutrition and hydration, respiratory care, dialysis services, food service quality and safety, infection control including COVID-19 protocols, and water management for Legionella prevention.
Deficiencies (20)
Failure to ensure residents were treated with dignity and timely response to call lights, resulting in residents waiting up to 111 minutes for assistance.
Failure to accommodate resident preferences and needs for edema treatment and comfort, including lack of timely care plan updates and environmental adjustments.
Failure to maintain sanitary, orderly, and comfortable environment in 22 of 105 resident rooms, including damaged walls, peeling sheetrock, exposed pipes, and dirty heater vents.
Failure to prevent resident-to-resident abuse involving multiple residents, inadequate supervision and care planning for aggressive residents, and failure to update care plans after incidents.
Failure to investigate an allegation of resident-to-resident physical abuse between Residents #29 and #99.
Failure to complete and transmit required Minimum Data Set (MDS) discharge assessment for Resident #58 upon discharge to the community.
Failure to provide individualized meaningful activities and consistent activity programming for residents with dementia on the memory support unit.
Failure to provide appropriate pressure ulcer care and prevention, resulting in progression to stage 4 pressure ulcer with infection requiring hospitalization for Resident #93, and worsening pressure wounds for Resident #62.
Failure to implement fall prevention interventions for Resident #186, resulting in resident found in bed with legs hanging off and bed in high position.
Failure to follow physician orders and timely address significant weight loss and nutritional needs for Residents #75, #79, and #111, including inconsistent provision of supplements and lack of swallowing assessments.
Failure to administer oxygen therapy at the ordered flow rate for Residents #185 and #2, and failure to document refusals or noncompliance.
Failure to ensure dialysis services were provided consistent with physician orders, including lack of communication with dialysis center, lack of physician orders for dialysis care, and failure to assess dialysis access site.
Failure to provide person-centered care and meaningful activities for residents with dementia, including lack of scheduled activities and lack of staff training on dementia care.
Failure to ensure food was palatable, served at appropriate temperature, and resident food preferences and allergies were accommodated, including frequent food complaints and lack of alternatives.
Failure to serve meals at regular times and prevent prolonged wait times for residents, with meal deliveries observed up to two and a half hours late.
Failure to maintain kitchen and food service areas in sanitary condition, including use of heavily scored and stained cutting boards, improper hand hygiene by dietary staff, and dirty kitchen surfaces and equipment.
Failure to ensure hospice services were coordinated with facility staff, including lack of written hospice care plan in resident record and lack of orientation for hospice staff.
Failure to implement effective infection prevention and control measures during COVID-19 outbreak, including improper use of PPE by staff, lack of resident mask use and isolation compliance, and inadequate disinfection of shared equipment.
Failure to offer and provide pneumococcal vaccination to Resident #43 despite documented eligibility and consent.
Failure to install backflow prevention devices on hand held shower hoses in resident rooms and shower room, increasing risk of water contamination.
Report Facts
Weight loss: 12
Weight loss: 5.56
Weight loss: 16.55
Temperature: 119
Temperature: 118
Temperature: 121
Temperature: 117
Water temperature: 106
Water temperature: 109
Water temperature: 110
Water temperature: 112
Water temperature: 123
Water temperature: 158
Water temperature: 160
Weight: 100
Weight: 92
Weight: 88
Weight: 108
Weight: 102
Weight: 165
Weight: 152
Weight: 142.7
Weight: 142.4
Weight: 137.7
Weight: 136.8
Weight: 130.1
Weight: 131.4
COVID-19 positive residents: 25
COVID-19 symptomatic residents: 26
COVID-19 positive staff: 18
New COVID-19 positive residents: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in findings for failure to respond timely to call lights and failure to provide drinks to resident #87 |
| CNA #3 | Certified Nurse Aide | Named in findings for failure to respond timely to call lights and failure to provide drinks to resident #87 |
| LPN #2 | Licensed Practical Nurse | Named in findings for failure to respond timely to call lights and failure to provide orientation |
| LPN #4 | Licensed Practical Nurse | Named in findings for failure to respond timely to call lights and failure to provide orientation |
| DON | Director of Nursing | Named in findings for failure to ensure timely response to call lights, failure to update care plans after abuse incidents, failure to ensure hospice coordination, failure to ensure oxygen therapy compliance, failure to ensure dialysis care coordination, failure to ensure nutrition interventions, failure to ensure infection control compliance |
| NHA | Nursing Home Administrator | Named in findings for failure to ensure timely response to call lights, failure to ensure hospice coordination, failure to ensure nutrition interventions, failure to ensure infection control compliance |
| CNA #7 | Certified Nurse Aide | Named in findings for failure to provide nutrition supplements to residents #75 and #79 |
| DM | Dietary Manager | Named in findings for failure to ensure food quality, failure to ensure timely meal delivery, failure to ensure kitchen sanitation, failure to ensure resident food preferences accommodated |
| WD | Wound Care Nurse | Named in findings for failure to ensure pressure ulcer care coordination and monitoring |
| CNC | Corporate Nurse Consultant | Named in findings for failure to ensure abuse investigations, failure to ensure nutrition monitoring, failure to ensure dialysis care coordination, failure to ensure infection control compliance |
| MTD | Maintenance Director | Named in findings for failure to ensure water temperature monitoring and Legionella prevention, failure to ensure backflow prevention devices installed |
| RN #2 | Registered Nurse | Named in findings for failure to ensure oxygen therapy compliance |
| RN #7 | Registered Nurse | Named in findings for failure to ensure glucometer disinfection |
| LPN #1 | Licensed Practical Nurse | Named in findings for failure to ensure glucometer disinfection |
| LPN #3 | Licensed Practical Nurse | Named in findings for failure to ensure glucometer disinfection |
Inspection Report
Routine
Census: 124
Deficiencies: 9
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, meal services, staffing, hygiene assistance, pressure ulcer prevention, ostomy care, vaccinations, and hydration in the nursing facility.
Findings
The facility was found deficient in multiple areas including timely meal service, medication administration, assistance with activities of daily living, pressure ulcer prevention, ostomy care, staffing adequacy, food quality and palatability, hydration provision, and vaccination policies. Residents and staff interviews, observations, and record reviews revealed delays, inadequate care, poor communication, and failure to follow care plans and policies.
Deficiencies (9)
Failure to ensure timely meal service and maintain residents' dignity during dining.
Failure to administer scheduled medications in a timely manner for multiple residents.
Failure to provide scheduled showers and baths or alternatives for residents unable to carry out ADLs independently.
Failure to implement interventions to prevent pressure injuries for a resident at risk.
Failure to provide necessary ostomy care consistent with professional standards and resident preferences, including monitoring for leakage and proper appliance fit.
Failure to provide sufficient nursing staff to meet residents' care needs, resulting in delayed and inadequate care.
Failure to ensure food was palatable, served at safe temperatures, and resident food complaints were addressed.
Failure to ensure residents consistently received drinks sufficient to maintain hydration and consistent with care plans and preferences.
Failure to develop and implement policies and procedures related to pneumococcal immunizations, including education on refusal and documentation.
Report Facts
Resident census: 124
Residents dependent on staff for bathing: 7
Residents needing assistance of one or two staff to bathe: 67
Residents dependent on staff for dressing: 1
Residents needing assistance of one or two staff to dress: 105
Residents dependent on staff for transfer: 15
Residents needing assistance of one or two staff to transfer: 58
Residents dependent on staff for toilet use: 30
Residents needing assistance of one or two staff to toilet: 69
Residents dependent on staff to eat: 3
Residents needing assistance of one or two staff to eat: 46
Residents frequently incontinent of bladder: 101
Residents frequently incontinent of bowel: 66
Residents in wheelchairs all or most of the time: 64
Residents with diagnosis of dementia: 44
Residents with current pressure injuries: 3
Residents receiving preventive skin care: 118
Residents receiving hospice services: 7
Residents receiving respiratory care: 45
Residents with contractures: 32
Residents on pain management program: 81
Inspection Report
Routine
Census: 124
Deficiencies: 9
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, meal services, staffing, hygiene assistance, pressure ulcer prevention, ostomy care, hydration, and vaccination policies.
Findings
The facility was found deficient in multiple areas including timely meal service, medication administration, assistance with activities of daily living, pressure ulcer prevention, ostomy care, adequate staffing, food quality and palatability, hydration, and vaccination procedures. Residents and staff interviews, observations, and record reviews revealed systemic issues such as delayed meals and medications, insufficient staff, inadequate hygiene care, poor food quality, lack of hydration support, and incomplete vaccination education and documentation.
Deficiencies (9)
Failed to ensure timely meal service and maintain residents' dignity during meal times.
Failed to ensure scheduled medications were given in a timely manner to multiple residents.
Failed to provide scheduled showers and baths or alternatives for dependent residents.
Failed to implement interventions to prevent pressure injuries for a resident at risk.
Failed to provide necessary ostomy care consistent with professional standards and resident preferences.
Failed to provide sufficient nursing staff to meet residents' care needs, resulting in delayed and inadequate care.
Failed to ensure food was palatable, served at safe temperatures, and resident food complaints were addressed.
Failed to ensure residents consistently received fluids according to care plans and preferences, and hydration carts were not available.
Failed to develop and implement policies and procedures for pneumococcal vaccinations, including education on refusal and documentation.
Report Facts
Resident census: 124
Residents dependent on staff for bathing: 7
Residents needing assistance of one or two staff to bathe: 67
Residents dependent on staff for dressing: 1
Residents needing assistance of one or two staff to dress: 105
Residents dependent on staff to transfer: 15
Residents needing assistance of one or two staff to transfer: 58
Residents dependent on staff for toilet use: 30
Residents needing assistance of one or two staff to toilet: 69
Residents dependent on staff to eat: 3
Residents needing assistance of one or two staff to eat: 46
Residents frequently incontinent of bladder: 101
Residents frequently incontinent of bowel: 66
Residents in wheelchairs all or most of the time: 64
Residents with diagnosis of dementia: 44
Residents with current pressure injuries: 3
Residents receiving preventive skin care: 118
Residents receiving hospice services: 7
Residents receiving respiratory care: 45
Residents with contractures: 32
Residents on pain management program: 81
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 2, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident self-determination, notification of change in condition, environmental safety and cleanliness, and prevention of accidents involving residents.
Complaint Details
The complaint investigation revealed failures in promoting resident self-determination, notification of changes to legal representatives, environmental safety and cleanliness, and prevention of resident injury from hot liquids. The facility was found to have past noncompliance with corrective actions implemented for the burn injury prior to the survey.
Findings
The facility failed to promote resident self-determination regarding daily routines and preferences for three residents, failed to timely notify a resident's legal representative of medication changes, failed to maintain a clean, safe, and homelike environment with multiple maintenance and housekeeping deficiencies, and failed to prevent a second-degree burn injury to a resident caused by hot liquid due to inadequate supervision and safety measures.
Deficiencies (4)
Failed to promote resident self-determination for three residents regarding daily care preferences and activities.
Failed to timely notify Resident #2's legal representative of medication changes and diagnostic results.
Failed to maintain a clean, safe, homelike environment including offensive odors, broken handrails, peeling paint, unsecured cables, and lack of clean linens.
Failed to prevent an accident involving hot liquid causing a second-degree burn to Resident #1.
Report Facts
Residents reviewed: 13
Residents affected: 3
Burn wound measurements: 3
Burn wound measurements: 9.3
Burn wound measurements: 0.1
Burn wound measurements: 1
Burn wound measurements: 3
Burn wound measurements: 2.5
Burn wound measurements: 2.8
Coffee temperature: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Acknowledged being Resident #2's regular daytime nurse and discussed medication changes |
| Nursing Home Administrator | NHA | Provided facility policies, interviewed regarding deficiencies and corrective actions |
| Maintenance Director | MTD | Discussed facility maintenance issues and repair priorities |
| Housekeeping Supervisor | HSKS | Discussed housekeeping deficiencies and cleaning protocols |
| Dietary Manager | DM | Discussed hot beverage preparation and safety procedures |
| Certified Nurse Aide #2 | CNA | Interviewed about Resident #1 care and injury |
| Certified Nurse Aide #3 | CNA | Reported Resident #1 injury to nurse and described observations |
| Licensed Practical Nurse #4 | LPN | Described Resident #1 behavior and injury circumstances |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, food service, and facility sanitation.
Findings
The facility was found deficient in multiple areas including failure to update resident care plans after falls, unsafe hot water temperatures, lack of medically related social services for discharge planning, medication administration errors, serving unpalatable and improperly timed meals, failure to provide snacks, and unsanitary food handling and storage practices.
Deficiencies (7)
Failed to update person-centered care plans to reflect changes in interventions after resident falls.
Failed to ensure water accessible to residents was maintained at safe temperatures in seven of 14 hallways.
Failed to provide medically related social services for discharge planning when requested by resident.
Medication error rate was 13.16% with five errors out of 38 opportunities observed.
Failed to serve palatable meals; residents reported food was hard, cold, tasteless, and portions were small.
Failed to serve meals and snacks at times consistent with resident preferences and posted mealtimes; meals were often late and snacks were not provided as needed.
Failed to maintain sanitary food handling and storage practices including improper hair restraints, raw eggs stored above ready-to-eat items, improper handwashing and glove use by dietary staff, and unlabeled/expired items in nourishment refrigerators.
Report Facts
Medication error rate: 13.16
Number of residents affected by hot water temperature issue: 7
Number of residents observed with meal service issues: 5
Number of residents affected by meal/snack timing issues: 136
Number of unlabeled/expired items observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication error finding for failing to administer medications as ordered. |
| RN #1 | Registered Nurse | Involved in fall incident reporting and medication administration observations. |
| Director of Nursing | Director of Nursing | Provided interviews regarding care plan updates, medication administration expectations, and food service issues. |
| Administrator | Administrator | Provided interviews regarding incident reporting, food service expectations, and social services staffing. |
| District Dietary Manager | District Dietary Manager | Provided interviews regarding meal service, snack provision, and food handling practices. |
| Registered Dietitian | Registered Dietitian | Provided interviews regarding meal service timing, snack provision, and sanitation rounds. |
| Dietary Aide #1 | Dietary Aide | Observed with improper hair restraint in kitchen. |
| Dietary Aide #2 | Dietary Aide | Observed with improper handwashing and glove use. |
| Social Service Director | Social Service Director | Interviewed regarding lack of discharge planning services. |
Inspection Report
Census: 138
Deficiencies: 16
Date: Dec 18, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care, staffing, infection control, and other aspects of facility operation.
Findings
The facility was found deficient in multiple areas including failure to promote resident self-determination, inadequate posting of state contact information, insufficient clean linens, failure to prevent and investigate abuse, inadequate assistance with activities of daily living, failure to provide person-centered activities, failure to maintain or improve resident mobility, unsafe environment with medical equipment plugged into non-medical power strips, multiple falls with major injuries, inadequate pain management, insufficient nursing staff, medication errors, improper medication storage, unpalatable food served at inappropriate temperatures, and ineffective quality assurance program.
Deficiencies (16)
Failure to promote resident self-determination and support resident rights to leave the facility at will.
Failure to post accurate state contact information and ombudsman contact information.
Failure to ensure clean linens including towels were available for resident use.
Failure to protect residents from sexual abuse and to investigate and monitor inappropriate sexual behaviors.
Failure to investigate and respond appropriately to allegations of potential abuse.
Failure to provide appropriate assistance with activities of daily living including meal assistance and nail care.
Failure to provide person-centered activities tailored to resident preferences and needs.
Failure to provide appropriate care to maintain or improve range of motion and mobility for residents with limited mobility.
Failure to ensure resident environment was free from accident hazards including medical devices plugged into non-medical grade power strips and use of space heaters in resident areas. Failure to prevent multiple falls with major injuries.
Failure to provide safe and appropriate pain management including thorough pain assessments and non-pharmaceutical interventions.
Failure to provide sufficient nursing staff with appropriate competencies and skills to meet resident care needs, resulting in delayed call light response, inadequate assistance with ADLs, and insufficient meal assistance.
Failure to ensure medication error rate was below 5%, including late insulin administration and administration of medication without physician order.
Failure to ensure drugs and biologicals were stored in locked compartments and not left unattended on medication carts or nurse stations.
Failure to serve food that was palatable, attractive, and at safe and appetizing temperatures.
Failure to implement an effective quality assurance program to identify and address facility compliance concerns, resulting in repeated resident falls and injuries and other quality issues.
Failure to ensure infection prevention and control practices including proper care and storage of oxygen equipment and cleaning of call light cords and bathroom environment.
Report Facts
Resident census: 138
Falls: 26
Medication error rate: 8
Staffing: 9
Staffing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed administering insulin late and applying medication without order |
| RN #3 | Registered Nurse | Observed keeping resident near nurse's cart and interviewed about 1:1 care |
| DON | Director of Nursing | Interviewed about restorative program, falls, medication administration, and QAPI |
| NHA | Nursing Home Administrator | Interviewed about staffing, QAPI, falls, and infection control |
| MTD | Maintenance Director | Interviewed about space heaters, call light cords, and infection control |
| CNA #7 | Certified Nurse Aide | Interviewed about staffing shortages |
| RN #1 | Registered Nurse | Interviewed about staffing and resident care |
| RN #5 | Registered Nurse | Interviewed about staffing and pain management |
| LPN #6 | Licensed Practical Nurse | Interviewed about resident pain and care |
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