Mountain View Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, facility staff failed to maintain one of 40 resident rooms in homelike condition, resident room [ROOM NUMBER]. The findings include:Facility staff failed to repair a section of wall next to the resident's bed in room [ROOM NUMBER]. On 10/08/2025 at approximately 12:24 p.m. an observation of resident room [ROOM NUMBER] revealed the left side of the bed against the wall. Observation of the wall next to the bed revealed the covering of the sheetrock was torn away in an area approximately 12 inches high by 16 inches wide. On 10/08/2025 at approximately 2:40 p.m. an observation of resident room [ROOM NUMBER] revealed the left side of the bed against the wall. Observation of the wall next to the bed revealed the covering of the sheetrock was torn away in an area approximately 12 inches high by 16 inches wide. On 10/08/2025 at approximately 4:20 p.m. an observation of resident room [ROOM NUMBER] revealed the left side of the bed against the wall. Observation of the wall next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide complete respiratory services for one of 19 residents in the survey sample, Resident #33.The findings include: For Resident #33 (R33), the facility staff failed to clarify oxygen rate of administration for as needed orders.On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/22/2025, the resident was assessed as being cognitively intact. R33 was not assessed as using oxygen at the time of the assessment.On 10/8/2025 at 2:23 p.m., an interview was conducted with R33 in her room. R33 was observed sitting in a chair with an oxygen concentrator at the bedside containing a nasal cannula inside of a closed plastic bag. When asked about oxygen, R33 stated that she wore the oxygen at night sometimes when she felt that she needed it.Review of the physician orders documented in part,Oxygen via nasal cannula or mask at bedtime for comfort. Order Date:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, and clinical record review, the facility staff failed to obtain a physician ordered laboratory test for one of 19 residents in the survey sample, Resident #3.The findings include: For Resident #3 (R3), the facility staff failed to obtain a magnesium level ordered by the physician on 5/21/25. A review of R3's clinical record revealed a physician's order dated 5/21/25 for a magnesium level and other laboratory (lab) tests every six months in March and September. Further review of R3's clinical record revealed the other laboratory tests were obtained on 9/19/25 but the magnesium level was not obtained. On 10/9/25 at 3:01 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated physician orders for labs are entered into the computer system, listed in a book, and documented on a lab sheet. ASM #2 stated the other ordered labs for R3 were obtained in September 2025, but the magnesium level was missed. On 10/9/25 at 3:42 p.m. ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, staff interview, and facility document review it was determined that the facility staff failed to implement the comprehensive care plan for one of 14 residents in the survey sample, Resident #7. The findings include: For Resident #7 (R7), the facility staff failed to implement the comprehensive care plan to check functioning of a WanderGuard device (1) used to monitor the resident for elopement. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/1/2023, the resident was assessed as being moderately impaired for making daily decisions. Section E documented R7 displaying behaviors of rejection of care during the survey dates and not wandering during the assessment period. The comprehensive care plan for R7 documented in part, (Name of R7) is a potential elopement risk/wanderer AEB (as evidenced by) Disoriented to place d/t (due to) recent admission r/t (related to) aging and her disease process. Date Initiated: 04/25/2023. Created on: 04/25/2023. Revision on: 04/25/2023. Under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice for medication administration, for two of 14 residents in the survey sample, Resident #7 and Resident #8. The findings include: 1. For Resident #7 (R7), the facility staff failed to clarify the dosing of an as needed order for the pain medication, Morphine Sulfate (1) oral solution. On the most recent MDS (minimum data set), an admission assessment with an ARD (Assessment Reference Date) of 5/1/2023, the resident was assessed as being moderately impaired for making daily decisions. Section J documented R7 receiving scheduled pain medications during the assessment period. The physician orders for R7 documented in part, Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (milligram per milliliter) (Morphine Sulfate) Give 1 dose orally every 4 hours as needed for moderate to severe pain rated 5-10 or if not taking po (by mouth) meds. Give 0.25ml or 0.50ml. Order Date: 07/04/2023. Start Date: 07/04/2023. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to monitor the function of Wander Guards used for the prevention of elopements, for two of 14 residents in the survey sample, Resident #7 and Resident #8. The findings include: 1. For Resident #7 (R7), the facility staff failed to monitor the functioning of the WanderGuard device (1) used to monitor the resident for elopement. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/1/2023, the resident was assessed as being moderately impaired for making daily decisions. Section E documented R7 displaying behaviors of rejection of care during the survey dates and not wandering during the assessment period. The physician orders for R7 documented in part, Wander Guard Bracelet for Safety every day shift for Safety, prevention of elopement. Order Date: 04/18/2023. Start Date: 04/25/2023. Review of the eTAR's (electronic treatment administration records) for R7 from 6/1/2023 through 8/1/2023 documented the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to adequately monitor a resident prior to administering a medication, for one of 14 residents in the survey sample, Resident #8. The findings include: For Resident #8 (R8), the facility staff failed to assess the heart rate prior to administration of Digoxin (1). The physician orders for R8 documented in part, Digoxin Oral Tablet 125 MCG (microgram) (Digoxin) Give 1 tablet by mouth every day shift related to Left Ventricular Failure, Unspecified. Order Date: 04/04/2023. Start Date: 04/13/2023. Review of the eMAR (electronic medication administration record) dated 6/1/2023-6/30/2023 for R8 documented Digoxin Oral Tablet 125 MCG (Digoxin) Give 1 tablet by mouth every day shift related to Left Ventricular Failure, Unspecified. The eMAR revealed documentation that the Digoxin was administered to R8 each day but failed to evidence a heart rate assessment prior to administration. Review of the eMAR dated 7/1/2023-7/31/2023 for R8 revealed documentation that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to ensure the required QAPI (quality assurance and performance improvement) committee members attended the QAPI meeting for one of four quarterly meetings in 2022. The findings include: The facility staff failed to ensure the Director of Nursing attended the second quarter QAPI meeting on 7/25/22. A review of the 7/25/22 QAPI meeting sign-in sheet failed to reveal the signature of the Director of Nursing. On 8/2/23 at 8:31 a.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator). ASM #1 stated QAPI meetings are held quarterly, and the Director of Nursing is supposed to attend. ASM #1 stated the former Director of Nursing did not attend the 7/25/22 QAPI meeting because he was on vacation. On 8/2/23 at 12:49 p.m., ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Quality Assurance and Performance Improvement documented, 2. The QA (quality assurance) Committee shall be interdisciplinary and shall: a. Consist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined the facility staff failed to store food in a safe and sanitary manner. The facility staff failed to dispose of expired food during an observation on 1/25/22 at 11:09 AM. The findings include: On 1/25/22 at 11:09 AM, an observation was conducted in the main kitchen. In the dry storage room, a 4.64 pound bag of dried milk was labeled opened 12/9/21, use by 1/9/22. A 49.6 ounce cornbread stuffing mix bag was labeled opened 10/15/21, use by 11/25/21. OSM (other staff member) #1, a dietary aide, was shown the two bags. When asked what the dates signified, OSM #1 stated, That means that they should be disposed of by those 'use by' dates. I will dispose of them now. OSM #3, the dietary manager, was informed of the expired items on 1/25/22 at 11:45 AM. A policy on food storage/expired food was requested on 1/26/22 at 3:20 PM. On 1/26/22 at 4:30 PM ASM (administrative staff member) #1, the administrator, was made aware of the above finding and stated, We do not have any policy regarding food storage or expired food. No further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to review and revise a comprehensive care plan for 2 of 19 residents in the survey sample; Residents #5 and #34. The findings include: 1. For Resident #5, the facility staff failed to review and revise the comprehensive care plan for the use of an opioid medication regarding the monitoring of related side effects and adverse reactions. Resident #5 was admitted to the facility on [DATE] and had the diagnoses of, but not limited to, insomnia, chronic kidney disease, rectal cancer, anxiety, depression, diabetes, high blood pressure, heart attack, atrial fibrillation, pacemaker, congestive heart failure, and hypothyroidism. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/9/22. The resident was coded as cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive assistance for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review it was determined that the facility staff failed to follow physician's orders for 1 of 19 residents in the survey sample, Resident #20. The facility staff failed to obtain a monthly weight in September 2021 for Resident #20. The findings include: Resident #20 was admitted to the facility on [DATE] and had the diagnoses of, but not limited to, hypothyroidism, epilepsy, depression, diabetes, high blood pressure, atrial fibrillation, and Alzheimer's disease. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/10/21. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living. A review of the clinical record revealed a physician's order dated 3/1/20 for Obtain weight monthly and as needed. A review of the weights documented in the clinical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, it was determined that the facility QAPI (quality assurance and performance improvement) committee failed to meet in two of four quarters in 2021. The facility QAPI committee failed to meet in the third and fourth quarters of 2021. The findings include: A review of QAPI committee meeting sign in sheets revealed meetings for the first and second quarters of 2021. The review failed to include sign in sheets for the third and fourth quarters of 2021. On 1/27/22 at 9:38 a.m., ASM (administrative staff member) #1, the administrator, was interviewed. He stated the QAPI committee includes him, the directors of personnel and discipleship, the director of nursing, the assistant director of nursing, the MDS (minimum data set) coordinator, the CNA (certified nursing assistant) supervisor, activities director, social services director, housekeeping supervisor, maintenance supervisor, dietary manager, occupational health nurse, consultant pharmacist, and medical director. He stated ordinarily the QAPI committee meets four times a year, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.