Mountain View Care Center

In the surveyor’s words

From the most serious findings on record at Mountain View Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 20, 2022

  Based on interview, record review and document review, the facility failed to ensure a resident with dementia who was assessed to be an elopement risk did not leave the facility premises unsupervised for 1 of 7 sampled residents (Resident 1). The failure to provide adequate supervision resulted in bodily injuries to the resident. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia, [CONDITION(S)] and [CONDITION(S)] with delusions, [CONDITION(S)], and major depressive disorder. […]

• No harm, potential for more than minimal, widespreadF802Dec 20, 2022

  Based on observation, interview, and document review, the facility failed to ensure adequate staff were on duty to provide adequate meal service. The failed practice affected 70 of 78 residents residing in the facility (excluding those residents being fed by the enteral route). Failure to provide adequate dietary staff can result in meals served late and cold food. Findings include: On 12/13/22 8:35 AM, the Cook and the Dietary Aide were performing breakfast tray-line service for the 300 Hall cart. These were the only employees present in the kitchen. A plate warming device was plugged in to the wall and it was full of metallic plate warmers which were very slightly warm to the touch. […]

• No harm, potential for more than minimal, widespreadF804Dec 20, 2022

  Based on observation, interview, and record review, the facility failed to ensure hot foods were served at a hot, palatable temperature for five of 25 sampled residents (Residents #93, #94, #96, #97, and #102), and for six non-sampled residents attending a group interview. The failed practices had an adverse effect on the resident's quality of life as evidenced by residents expressing disappointment and loss of enjoyment due to being served cold food. Findings include: On 12/13/22 8:35 AM, the Cook and the Dietary Aide were performing breakfast tray-line service for the 300 Hall cart. These were the only employees present in the kitchen. A plate warming device was plugged in to the wall and it was full of metallic plate warmers which were very slightly warm to the touch. […]

• No harm, potential for more than minimal, widespreadF880Dec 20, 2022

  Based on observation, interview, record review and document review, the facility failed to ensure 1) a staff member donned the appropriate personal protective equipment prior to entering the COVID-19 room and 2) N95 mask fit testing was completed for the employees. The failure could potentially prevent the staff members from protecting themselves and others from COVID-19 infection. Findings include: 1) Personal Protective Equipment (PPE) Resident 8 (R8) R8 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD). A COVID Testing Result dated 12/07/2022, documented R8 was positive for COVID-19. Resident 201 (R201) R201 was admitted on [DATE], with diagnoses including cerebral palsy. […]

• No harm, potential for more than minimal, widespreadF885Jan 7, 2022

  Based on interviews and document review, the facility failed to ensure all residents, family members, and resident representatives were informed whenever a new COVID-19 case was identified in the facility. Findings include: A Memorandum from the Centers for Medicare and Medicaid Services (CMS) QSO-20-29-NH dated 05/06/2020, documented residents, their representatives, and families of those residing in facilities should be informed by 5:00 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other. […]