Mountain View Assisted Living

The facility failed to ensure quarterly pharmaceutical reviews were completed for three sampled residents. Specifically, no documentation of quarterly pharmacy reviews was found for these residents after May 2021 due to a failure in the contracted pharmacy's oversight of their replacement contractor.

The facility failed to ensure quarterly pharmaceutical reviews were completed for three sampled residents. Specifically, there was no documentation of quarterly pharmacy reviews being performed for Resident #1 after May 20, 2021.

The facility failed to implement and maintain CDC and NC DHHS guidance regarding staff and visitor screening. Specifically, the facility did not ensure personnel were screened for fever and symptoms before shifts, failed to post required signage at entrances, and did not properly screen essential visitors for COVID-19 symptoms.

The facility failed to ensure a resident on a physician-ordered pureed diet with nectar-thickened liquids received the correct food consistency. Observations showed that while some items were pureed, the ham and collard greens were only provided in a ground consistency. Staff interviews revealed that cooks were not consistently using therapeutic diet references and were substituting foods based on personal preference rather than medical orders.

The facility failed to ensure a therapeutic diet was served as ordered for one resident who required a pureed diet with nectar-thickened liquids. During meal service, the resident was served meat and greens in a ground consistency rather than pureed, and the cook stated he did not realize pureed food needed to be processed to that specific consistency.

The facility failed to ensure a resident with a prescribed Mechanical Soft diet was served food according to physician orders. During meal observation, the resident was served meat pieces and salad vegetables that were not appropriately modified for the required diet. Additionally, the cook was unable to locate therapeutic menus and was using incorrect guidance for meal preparation.

The facility failed to ensure a resident on a Mechanical Soft diet was served the correct diet texture. Specifically, the resident was served beef pieces that were too large and tough to chew, and a tossed salad with large vegetable pieces instead of the required shredded/ground preparation. Additionally, kitchen staff were unable to locate the modified diet menus for guidance.