Mountain View Post Acute

Construction Deficiencies

Use approved construction type or materials.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Meet other general requirements that are deficient.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Have enough outside ventilation via a window or mechanical ventilation, or both.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Miscellaneous Deficiencies

Have restrictions on the use of flammable curtains.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

A complaint survey, prompted by Incident #39899 and complaints #CO39645,#CO39674 and #CO39884 was conducted on 4/15/25 to 4/16/25. Two deficiencies were cited. Based on observations, record review and interview, the facility failed to ensure the call light system was functioning properly in its entirety. Specifically, the facility failed to ensure staff could hear the call light alerts when working in areas away from the centralized staff work area, where the call light alarm sound was heard when there were no staff in the centralized work area to hear the alarm. Findings include:I. Facility policy and procedureThe Call Lights: Accessibility and Timely Response policy, revised 1/25/25, was provided by the nursing home administrator (NHA) on 4/16/25 at 3:45 p.m. It read in pertinent part: "The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident' s bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response."II. ObservationsOn 4/15/25 at 10:56 a.m., during the walkthrough of the facility, the call light system was observed. The audible call light alarm only sounded at the nurses' station and could not be heard down the unit' s hallways. A light board was located in the nurses' station with a square button for each resident room that illuminated when a resident activated the call light. Outside of the enclosed nurse' s station, the activated call lights were not easily visible. Ther.. Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents out of seven sample residents received the highest practicable treatment and care per professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure Resident #6 received her medications in a timely manner, as prescribed. Findings include:I. Professional referenceAccording to Potter, P.A. and Perry, A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 607-609. "Medication errors can cause or lead to inappropriate medication use or patient harm. Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval. Administering extra doses, and/or failing to administer medications. Preventing medication errors is essential. "Professional standards such as the scope of nursing and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medication ...The right medication, the right dose; the right patient; the right route; the right time; right documentation; and the right indication."Give priority to time-critical medications that must act and therefore be given at certain times. Give all r..

A survey prompted by #CO39277, #CO39339 and #CO39354 was conducted 2/25/25 to 2/26/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain and maintain the highest practicable mental and psychosocial wellbeing for one (#2) of three residents reviewed out of five sample residents. Specifically, the facility failed to ensure services and individualized care approaches were provided, and monitored with ongoing assessment, for Resident #2 in order to meet the emotional and psychosocial needs of the resident.Findings include:I. Resident #2A. Resident statusResident #2, age 69, was admitted on 12/20/24 and discharged to another long-term care facility on 2/13/25. According to the February 2025 computerized physician orders (CPO), diagnoses included anxiety, head injury, dementia, depression and epilepsy.The 12/27/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status score (BIMS) of eight out of 15. He required supervision with dressing, bathing, ambulation, transfers and hygiene. The assessment indicated the resident had no behaviors.B. Record reviewResident #2' s psychosocial emotional trauma care plan, initiated 12/27/24, revealed the resident was at risk for psychosocial and adjustment issues related to emotional distress, ineffective coping skills, and poor impulse control with a history of traumatic events, to include the sudden and expected death of his wife and recent appointment of a guardian. Interventions included attempting non-pharmacological approaches, such as music therapy, breathing exercises, talking to the resident about his feelings, meditation, aroma therapy, offering reading materials and offering behavioral and psychological services as indicated. Review of Resident #2' s February 2025 CPO revealed the following physician' s orders:Trazodone 50 mg (milligrams), give one tablet by mouth for insomnia one time per day, ordered 12/20/24.Cel..