Mountain View Manor

In the surveyor’s words

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

• Actual harm, isolatedF686Mar 28, 2023

  Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure that care and services related to pressure ulcer was provided for 1 of 3 sampled residents (#1). The deficient practice could result in developing and/or worsening of the pressure ulcer. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included cerebrovascular disease, congestive heart failure, severe protein-calorie malnutrition, and type II diabetes. A skin/wound observation dated February 23, 2023 included the skin was intact. A Braden Scale Risk assessment dated [DATE] revealed the resident's sensory perception was slightly limited, the skin was often moist and the resident's activity level was bedfast with very limited mobility. […]

• No harm, potential for more than minimal, widespreadF758Feb 22, 2023

  Based on clinical record reviews, staff interviews, and review of policy and procedure, the facility failed to ensure target behavior and adverse side effects related to psychotropic medication use were monitored for 7 of 9 sampled residents (#6, #24, #29, #38, #40, #109 and #110). The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: -Resident #24 was admitted on [DATE] with diagnoses of bipolar disorder, insomnia, major depressive disorder, panic disorder, mild cognitive impairment and dementia. A review of the comprehensive care plan dated June 22, 2022, revealed a focus of antianxiety, antidepressant and antipsychotic medication usage. […]

• No harm, potential for more than minimal, patternF600Feb 28, 2025

  Based on clinical record review, facility documentation, observation, staff interviews, and policy review, the facility failed to ensure that three residents (#36, #223, and #49) were free from abuse. The deficient practice may result in further staff to resident abuse. Findings Include: Resident #36 was admitted on [DATE] with diagnoses that included atrial fibrillation, sequelae of cerebral infarction (stroke), aphasia, dysphagia, anxiety disorder, major depressive disorder, and right hip pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was independent in cognitive skills for daily decision making, and her decisions are consistent and reasonable with no behavioral concerns. […]

• No harm, potential for more than minimal, patternF607Feb 28, 2025

  Based on staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database, the facility failed to implement their policy to effectively prevent abuse for three residents (#223, #36, and #49). The deficient practice could result in abuse continuing and not being prevented. Findings include: Resident #223 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. […]

• No harm, potential for more than minimal, patternF842Feb 28, 2025

  Based on clinical record review, interviews and facility policy review, the facility failed to ensure medical records were completed and accurately documented for three residents (#49, #36, and #223). The deficient practice may result in the incompletely kept medical records and not being accurate. -Findings include: Resident #223 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. […]