Mountain View Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mountain View Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 7, 2024

  Based on observation, clinical record review, interview, and document review the facility failed to protect residents from physical abuse for 2 of 28 sampled residents (Resident #72 and #104) from resident to resident abuse. Resident #104 obtained a facial fracture resulting in actual harm. Resident #72 obtained lacerations requiring eight staples resulting in actual harm. Findings include: Resident #72 Resident #72 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease and anxiety disorder. Diagnoses added on 10/31/2024, included laceration without foreign body of scalp, subsequent encounter, and unspecified injury of the head, subsequent encounter. […]

• No harm, potential for more than minimal, widespreadF761Nov 7, 2024

  Based on observation, interview, and document review, the facility failed to ensure 1) a medication cart containing resident medications was secure, 2) an open multi-dose vial had the date opened and initials of the first person to use the vial written on it in 1 of 2 medication storage rooms reviewed and 3) outdated medications were removed from 3 of 3 medication carts reviewed and 1 of 2 medication storage rooms reviewed. The deficient practice could have facilitated unauthorized access to medications in the cart and had the potential for outdated/expired medications to be administered to residents. Findings include: Unsecured Medications On 11/07/2024 at 9:14 AM, the Director of Nursing Services (DNS) verbalized medication carts should be secure when not in use. […]

• No harm, potential for more than minimal, widespreadF755Nov 16, 2023

  Based on observation, interview and document review, the facility failed to accurately document the amount of a controlled substance in 2 of 2 sampled controlled substance logs and failed to ensure the discrepancies were reported to the Director of Nursing (DON). Findings include: On 11/14/23 at 2:03 PM, a controlled substance reconciliation count was completed for the 300 hall medication cart's controlled substance log with the DON and the following inaccuracies were identified. The controlled substance log documented the following: -On 11/09/23 at 8:00 AM, a 0.25 milliliter (ml) dose of morphine sulfate concentrate (morphine) was documented as administered, and 4.0 ml of the medication remained in the bottle. […]

• No harm, potential for more than minimal, widespreadF812Oct 14, 2021

  Based on observation and interview, the facility failed to ensure one of two hand washing stations in the kitchen were stocked with hand soap and disposable towels to prevent cross-contamination and foodborne illnesses. Findings include: On 10/11/21 at 7:47 AM, the Dietary Manager attempted to use the hand washing station located next to the dish washing machine. The Dietary Manager turned on the water to the faucet and pressed the soap dispenser hanging on the wall next to the sink several times. No hand soap came from the dispenser. The Dietary Manager then pressed down on the lever to the paper towel dispenser hanging on the wall above the soap dispenser. No paper towels came from the dispenser. […]

• No harm, potential for more than minimal, patternF759Nov 7, 2024

  Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 26 opportunities and 14 medication errors. The medication error rate was 53.85%. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 11/07/2024 at 8:07 AM, a Licensed Practical Nurse (LPN) began preparing to administer medications to Resident #4. Among the medications prepared were the following: -Cholecalciferol (Vitamin D) 1000 units, two tablets. -Loratadine 10 milligrams (mg), one tablet. […]