Mountain View Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Apr 23, 2022

  Based on observation, interviews, and record reviews, the facility failed to ensure that two of four residents (49 and 51) reviewed for pressure ulcers received care and services to prevent, monitor, and treat pressure injuries. This failure resulted in both residents' deep tissue injuries to progress into advanced stages of pressure ulcers resulting in gangrene and amputation of Resident 49's right above the knee lower extremity, constituting an immediate jeopardy. Refer to initial comments page for information pertaining to immediate jeopardy identified on 04/21/22. Findings included . Review of the facility's policy titled Skin monitoring and management dated 06/2016, indicated it is the policy of this facility that: 1. […]

• Actual harm, patternF725Apr 4, 2022

  Based on observations, interviews and record review, the facility failed to 1) meet the needs or wants of residents, 2) ensure there was sufficient numbers of nursing staff to provide care and services, 3) ensure all residents received showers per their preference, 4) answer call lights timely, and 5) ensure residents were provided timely incontinent care/toileting assist for five of six residents (1, 2, 5, 6, & 11) reviewed for care concerns. These failures resulted in harm related to anxiety, feelings of frustration and vulnerability, unmet care needs, discomfort/pain, and a diminished quality of life. […]

• Actual harm, isolatedF600May 25, 2022

  Based on interview and record review the facility failed to ensure one of three residents (1) reviewed for abuse were free from abuse. The facility failed to re-educate all staff on abuse and neglect following the abuse, re-educate staff on how to manage residents exhibiting behaviors, and to monitor the resident for signs of psychosocial harm. Based on the reasonable person concept this failure would have caused psychosocial distress to Resident 1 who was verbally abused by a staff member while experiencing respiratory distress and placed other residents at risk for staff to resident or resident to resident abuse. Findings included . Review of the facility Abuse Prevention & Investigation policy, revised 4/2019, Each resident has the right to be free from abuse. […]

• Actual harm, isolatedF557Apr 4, 2022

  Based on observations, interviews and record review, the facility failed to provide care in a manner that promoted resident respect and dignity for one of three residents (3) reviewed. According to the reasonable person concept, failure to provide incontinent care for this cognitively impaired resident in a timely manner would have reasonably resulted in embarrassment, humiliation, diminished self-worth, and psychosocial harm. Findings included . Resident 3 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease and major depressive disorder. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had both short and long term memory impairment. […]

• No harm, potential for more than minimal, widespreadF812Apr 23, 2022

  Based on observation, interview, and review of facility policies, the facility failed to properly label, store or remove expired food items from food inventory, and one of two staff (Staff ) observed assisting residents to eat failed to use appropriate hand hygiene while assisting residents to eat in the dining room. These failures had the potential to increase the risk of food borne illnesses and affect 53 of 53 residents living at the facility that are provided their meals from the facility kitchen. Findings included . Review of the facility's undated policy titled General Storage Standards stated .All potentially hazardous, ready-to-eat food that is prepared on-site must be labeled with the date prepared and can be stored for a maximum of seven (7) days. […]