Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain View Manor Nursing Center during CMS and state inspections, most recent first.
Food items in the walk-in cooler were found with expired use-by dates, missing labels or dates, and signs of spoilage, including discolored lettuce and opened cheese products left improperly stored. Surveyors also observed pink and brown substances on the kitchen ice machine baffle above the ice trough. The Head [NAME] acknowledged the storage issues and that the ice machine needed cleaning, while the DDM and Administrator stated that food labeling, dating, spoilage checks, and ice machine sanitation were expected.
MDS assessments were inaccurately coded for falls and PASRR for multiple residents. One resident’s MDS did not fully reflect two documented falls, including one with a major injury, and several residents with documented Level II PASRR determinations were coded as not currently considered by the state PASRR process to have SMI/ID or a related condition. Staff interviews confirmed the chart contained the PASRR information, but the MDS entries did not match the record.
Missing Discharge Care Plan: A resident with OCPD and intact cognition did not have a discharge care plan despite care plan meetings discussing short-term stay, psychiatric services, and later transfer to a long-term psych facility. The comprehensive care plan had no discharge plan, and staff interviews showed confusion between the SW and MDS Coordinator about who was responsible for developing it.
The facility failed to submit Level II PASRR requests for two residents admitted with PTSD, depression, and anxiety diagnoses. Both residents had Level I PASRR screenings that did not document mental health diagnoses, while later psych notes showed active psychiatric conditions and treatment with antidepressants and anxiolytics. The SW confirmed she was responsible for PASRR re-evaluations and said the omission was an oversight.
Expired Vitamin B12 was administered to a resident after an MA gave a daily dose from a medication cart bottle that had an expiration date of 1/2026 and still contained 92 pills. During the med storage observation, the MA stated she had already given the expired dose that morning and admitted she did not check the expiration date before administration. The MAR confirmed the resident received the Vitamin B12, and the DON and Administrator stated their expectation was that residents receive non-expired medications.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
Unsecured Medication Cart and Expired Medications: An unlocked, unattended med cart was observed in a nursing station with open access, and expired Vitamin B-12 was found on another cart. An MA stated she administered the expired medication without checking the expiration date, while the DON said staff were expected to verify expiration dates and keep med carts locked when unattended.
Pureed diet foods were not consistently prepared to the required pudding-like consistency for two residents with dysphagia diets. During meal observation and a test tray review, the SLP and Dietary leadership found that some pureed items were smooth, but others, including a dessert item, were thick and sticky like peanut butter and did not slide off the spoon. The SLP, RD, District Dietary Manager, and Administrator all acknowledged ongoing inconsistency in pureed food preparation, with staff turnover and lack of a standard recipe contributing to the issue.
Unresolved Resident Council Dietary Concerns: Residents repeatedly voiced ongoing food and meal service complaints, including unmet preferences, late meals, missing snacks, and inconsistent tray delivery. Council minutes showed the same dietary issues carried forward month after month without clear resolution, while residents and the Dietary Mgr confirmed the concerns continued despite repeated discussion with facility leadership.
Surveyors identified deficiencies in food storage and handling, including undated and uncovered food items in the walk-in cooler and freezer, as well as expired canned food in dry storage. The Dietary Manager and Administrator confirmed that these items were not managed according to manufacturer guidelines or best-by dates.
The facility did not follow its abuse and misappropriation policies by failing to maintain complete investigation records, not immediately reporting allegations to the Administrator or designee, and not notifying law enforcement or APS in several cases. Incidents included medications found in a nurse's personal bag, possible diversion of a resident's Morphine, and concerns about a nurse's conduct during medication administration. Required documentation and timely reporting to external agencies were not completed as per policy.
A resident with chronic respiratory conditions and a physician's order for continuous oxygen was observed receiving oxygen therapy, but the admission MDS assessment failed to document this oxygen use.
Two residents were affected when baseline care plans were not developed or accurately completed within 48 hours of admission. One resident with chronic respiratory failure did not have a baseline care plan created, and another with diabetes had a care plan that failed to document their diagnosis and insulin therapy, despite physician orders. Staff interviews confirmed these omissions and clarified that the admitting nurse was responsible for timely and accurate completion.
A resident dependent on staff for bathing, with diagnoses including COPD and heart failure, did not receive scheduled showers on multiple occasions. Documentation and staff interviews confirmed that showers were missed on certain days, and alternative hygiene measures were not offered. The resident reported feeling unclean as a result.
A resident with chronic respiratory conditions was observed receiving continuous oxygen therapy via nasal cannula, but no cautionary or safety signage was posted outside the room to indicate oxygen use. Staff interviews revealed uncertainty about who was responsible for placing the signage and where it was kept, and facility leadership confirmed the signage should have been in place but was not.
A resident who was not approved for self-administration of medications was found with a tube of Hydrocortisone cream and a medication cup containing an unidentified gel left unsecured at the bedside. The resident reported using both items, one of which was brought by family, and staff interviews confirmed that medications should not have been left in the room. The DON and nurses acknowledged the error, and the administrator stated that medications are expected to be stored properly.
A nurse failed to wear a gown while administering tube feeding to a resident on Enhanced Barrier Precautions, despite facility policy requiring both gown and gloves for such high-contact care. The nurse was unsure about the application of precautions, and leadership confirmed that proper PPE should be used when signage is present.
A nurse aide engaged in a verbal altercation with a resident who had moderate cognitive impairment, raising her voice and arguing after the resident fell while attempting to use the bathroom unassisted. Multiple staff witnessed the aide's disrespectful and aggressive behavior, which caused the resident to become upset and required intervention by a nurse to de-escalate the situation.
A resident with severe cognitive impairment and a PRN order for lorazepam had two of their prescribed pills found in another resident's room. A nurse signed out and documented the pills as wasted, with another nurse signing as a witness without actually observing the waste. The medication was not administered as ordered, and required documentation was incomplete, resulting in substantiated diversion of controlled medication.
Food Storage and Ice Machine Sanitation Deficiencies
Penalty
Summary
Food was found stored in the walk-in cooler with multiple labeling and dating problems and several items showing signs of spoilage. During an observation with the Head [NAME], surveyors found containers of tuna, tomato soup, alfredo, brown gravy, cheezy rice, and egg salad with use-by dates that had passed, a metal steam pan with no label or date that appeared to contain grated cheese over pasta with a white creamy sauce, chicken noodle soup with no date, opened mozzarella cheese with no date, and an opened package of sliced American cheese left open to the air with no opened-on or use-by date. Two sealed bags of lettuce were also observed with brown discoloration and brown liquid in the bottom of the bags. Surveyors also observed the kitchen ice machine with pink and brown substances scattered across the entire baffle directly above the full trough of ice. During the observation, the Head [NAME] stated he understood that items were not stored correctly and that the ice machine needed to be cleaned. The District Dietary Manager stated that it was the Head Cook's or Food Service Manager's responsibility to ensure food was labeled and dated, that stored food should be checked daily for proper labeling and signs of spoilage, and that the ice machine should be wiped down daily with a monthly deep clean by maintenance. The Administrator stated that all food was expected to be labeled, dated, and stored correctly, spoiled items discarded immediately, and the ice machine maintained and sanitized properly.
MDS Assessments Incorrectly Coded for Falls and PASRR
Penalty
Summary
The facility failed to accurately code MDS assessments in the areas of falls and PASRR for 7 of 22 residents reviewed for MDS accuracy. The record review and staff interviews showed that several MDS assessments completed by a traveling MDS Coordinator did not match information documented in the residents’ medical records, including fall events and Level II PASRR determinations. For one resident admitted with chronic respiratory failure with hypoxia and a healing left humerus fracture, the admission MDS coded a fall in the last month and a fracture related to a fall prior to admission. However, nurse progress notes documented two separate falls after admission: one in which the resident rolled out of bed and landed on her buttocks, and another in which the resident was found on the floor next to the bed with right hip pain and was sent to the ER. Hospital records showed an acute comminuted impacted right intertrochanteric fracture, and the discharge MDS coded only one fall with major injury. The MDS Coordinator later stated the resident had two falls since the prior assessment and that the discharge MDS should have reflected one fall with no injury and one fall with major injury. For six residents, the MDS assessments did not accurately reflect existing Level II PASRR determinations. The records showed Level II PASRR notification letters for residents with diagnoses including anxiety disorder, bipolar disorder, unspecified dementia with psychotic disturbances, schizoaffective disorder, major depressive disorder, and other psychiatric conditions. The annual, significant change, or admission MDS assessments for these residents stated they were not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, despite documentation in the chart showing active PASRR determinations. Staff interviews confirmed the PASRR letters were in the EMR and that the MDS Coordinator was responsible for coding PASRR, but the assessments were still coded without the Level II PASRR information.
Missing Discharge Care Plan
Penalty
Summary
The facility failed to develop a discharge care plan for Resident #83, who was admitted with obsessive-compulsive personality disorder (OCPD). A care plan meeting on 12/01/25 documented that the resident did not wish to attend and that the interdisciplinary team, including the Business Office Manager, Social Worker, DON, and Administrator, discussed that she would remain at the facility short-term, receive psychiatric services before discharging home, and had no barriers to discharge. The admission MDS assessment noted the resident had intact cognition, her overall goal was to discharge to the community, there was no active discharge planning in place, and she did not want to be asked about returning to the community on all MDS assessments. A later care plan meeting on 01/21/26 documented that the resident again did not attend and that her recent inpatient psychiatric admission was discussed, with Family Member #1 stating they now wanted her transferred to a long-term psychiatric facility for treatment. Review of the comprehensive care plan, last revised on 03/03/26, showed no discharge care plan. The discharge-return not anticipated MDS indicated the resident discharged to an inpatient psychiatric facility. During interviews, the SW stated discharge planning begins on admission and that the MDS Coordinator was typically responsible for the discharge care plan, while the MDS Coordinator said there was confusion about whether the MDS Coordinator or SW was responsible and confirmed the resident did not have a discharge care plan. The Administrator stated a discharge care plan should be part of the comprehensive care plan and that the SW was responsible for starting discharge planning on admission and documenting updates as needs or goals changed.
Failure to Submit Level II PASRR Requests for Residents With Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for two residents who were admitted with serious mental health diagnoses. One resident was admitted with PTSD, depression, and anxiety disorder, and the record showed a Level I PASRR screening that did not document mental health diagnoses. The admission MDS indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, and a psychiatric evaluation later documented ongoing treatment with sertraline and lorazepam for depression, anxiety, and PTSD. The facility could not provide documentation that a Level II PASRR request had been submitted for this resident. The second resident was admitted with PTSD, major depressive disorder, and anxiety disorder, and the Level I PASRR screening again noted a PASRR-only review with no mental health diagnoses documented. The admission MDS showed the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, while psychiatric notes documented active diagnoses of major depressive disorder, generalized anxiety disorder, PTSD, and dementia with behaviors, along with antidepressant treatment and later lorazepam for anxiety. The facility was unable to provide documentation that a Level II PASRR request had been submitted for this resident. The social worker confirmed she was responsible for submitting PASRR re-evaluation requests and stated the omission was an oversight; the administrator stated she would expect a Level II PASRR request when a resident was admitted with a Level I PASRR and mental health diagnoses.
Expired Vitamin B12 Administered to Resident
Penalty
Summary
The facility failed to prevent the administration of an expired medication for Resident #71, who had been admitted to the facility and had a physician's order dated 4/30/26 for Vitamin B12 oral tablet 500 micrograms by mouth daily as a supplement. During a medication storage observation on 7/8/26 at 8:45 AM, a bottle of Vitamin B12 500 MCG with an expiration date of 1/2026 was found on the A Hall Medication Cart with 92 pills remaining. The Director of Nursing Services and Medication Aide #1 were present during the observation. Medication Aide #1 stated that the expired Vitamin B12 had already been administered to one resident that morning and reported that Resident #71 had received one pill of the expired Vitamin B12 500 MCG. She stated she became aware the medication was expired when it was discovered during the observation and said she should have checked the expiration date before giving it, explaining she did not think to look before administering the dose. Review of the MAR at 8:55 AM confirmed Resident #71 received Vitamin B12 oral tablet 500 MCG that morning. The DON stated he expected the Nurse or MA to check expiration dates before administering any medication, and the Administrator stated her expectation was for residents to receive medications that were not expired.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Unsecured Medication Cart and Expired Medications
Penalty
Summary
Drugs and biologicals were not stored and handled in accordance with accepted professional principles when an unattended medication cart was found unlocked in the C and D Hall nursing station and expired medications were found on the A Hall medication cart. During observation, the C Hall medication cart was left unlocked and unattended inside a nursing station that had two accessible entrances, including one open entrance with no door. The Director of Nursing Services stated the cart should be locked when unattended, and Nurse #1 stated she had locked the cart after handoff but was unsure why it was unlocked and said she was the only person with a key. On the A Hall medication cart, a bottle of Vitamin B-12 500 mcg with an expiration date of 1/2026 was available for use, and Medication Aide #1 stated she had administered it to a resident without checking the expiration date. A second bottle of Vitamin B-12 1000 mcg with an expiration date of 6/2026 was also observed on the cart. The DON stated nurses or MAs were expected to check expiration dates before administering medications and to remove expired medications from carts at the start of each shift, and the Administrator stated expired medications should be removed from medication carts and replaced with non-expired medications.
Pureed Diet Foods Served at Incorrect Consistency
Penalty
Summary
The facility failed to serve pureed food items in the applesauce- or pudding-like consistency required for residents with advanced dysphagia diets. During lunch meal observation, the SLP reported that residents ordered pureed diets could not eat the food because it was too thick to swallow, describing the pureed items from the kitchen as paste-like rather than the expected applesauce-like consistency. She stated that when she observed pureed food that was too thick, she returned it to the kitchen so dietary staff could add more liquid, and she attributed the inconsistency to high dietary staff turnover and inadequate training. A test tray reviewed with the District Dietary Manager showed that the pureed chicken, collard greens, mashed potatoes, and bread were smooth and pudding-like, but the pureed brownie was thick and sticky, similar to peanut butter, and could not be shaken off the spoon. The District Dietary Manager agreed the brownie was too thick and said it needed more milk to reach the correct consistency. The SLP, RD, District Dietary Manager, and Administrator all acknowledged ongoing inconsistency in pureed food preparation, with the SLP stating that for the past year the food was often paste- or peanut butter-like and the District Dietary Manager noting there was no recipe for pureeing the items, making consistency difficult to maintain.
Unresolved Resident Council Dietary Concerns
Penalty
Summary
The facility failed to resolve and communicate its efforts to address repeated dietary concerns raised by residents during Resident Council meetings over multiple months. Resident Council minutes from January through July 2026 documented ongoing complaints that food was the main concern, menus did not reflect resident likes and dislikes, snacks were not being passed, meats were processed, residents were waiting for meals, preferences were not being honored, meals were late, and meal delivery was inconsistent. The minutes also noted that old business was repeatedly carried forward because concerns from prior meetings had not been resolved or followed up by administration. Residents interviewed during the survey reported continued dietary problems, stating that food preferences were not being followed and that menu choices provided to staff did not match what residents received. The Dietary Manager acknowledged awareness of the recurring food concerns and stated she attended Food Committee meetings held after Resident Council, where similar issues were discussed each month. The Activity Director, Social Worker, and Administrator each described a process in which grievances from Resident Council minutes were transferred to grievance forms and reviewed, but the Resident Council continued to report unresolved food issues across several months, including missed dinner trays when a resident was out with family.
Deficient Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and handling practices. In the walk-in cooler, a box of thawed premade peanut butter and honey sandwiches was found with only the date it was placed in the cooler, and staff were unsure how long the sandwiches were safe to use after thawing. The Dietary Manager was unable to locate manufacturer guidelines for the product's shelf life after thawing. In the walk-in freezer, two bags of french toast were found without dates, and a box of frozen pizzas was left open to air, both of which the Dietary Manager acknowledged should have been dated and covered by staff. Additionally, in the dry storage room, two and a half cases of canned pureed turkey were found with a best-by date that had already passed. The Dietary Manager confirmed that these items should have been used or discarded by the best-by date. The Administrator stated that his expectation was for all food to be stored, dated, and used or discarded according to manufacturer guidelines and best-by dates.
Failure to Implement Abuse and Misappropriation Reporting and Investigation Procedures
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation policy and procedure by not maintaining complete evidence of investigations into misappropriation of property and not immediately reporting allegations of abuse to the Administrator or designee, as well as not notifying local law enforcement or Adult Protective Services (APS) for several abuse or misappropriation allegations. In one instance, medications belonging to multiple residents were found in a nurse's personal bag at the nurse's station. The facility's investigation included a statement from the nurse and interviews with alert and oriented residents, but lacked documentation such as the names and amounts of medications found. Attempts to interview the nurse were unsuccessful, and the former DON reported that documentation of her investigative actions was missing. The Administrator and Corporate Nurse were unable to account for the missing documentation or recall all investigative steps taken. In another case, an allegation of possible diversion of a resident's liquid Morphine was reported after the medication was found to be an abnormal color. The allegation was not reported to law enforcement or APS, and the Social Worker stated she did not notify these agencies because she was not instructed to do so by the Administrator. The investigation included interviews with nurses and returning the medication to the pharmacy, but the reporting requirements to external agencies were not met. The Administrator confirmed that the Compliance Officer did not instruct him to notify law enforcement or APS. A further incident involved an allegation of resident abuse related to a nurse's conduct and medication administration. The allegation was not reported to law enforcement or APS, and the initial report was not submitted within the required two-hour timeframe. The Social Worker and Administrator both indicated that reporting to external agencies was not completed because they were not instructed to do so. The investigation documentation was incomplete, and key staff involved were unavailable for interview. These failures demonstrate lapses in following the facility's own policies and regulatory requirements for reporting and investigating abuse, neglect, and misappropriation allegations.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment regarding oxygen use for one resident. The resident was admitted with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, and had a physician's order for continuous oxygen via nasal cannula at 3 liters per minute, with instructions to titrate to maintain oxygen saturation above 90%. Despite this order and an observation confirming the resident was receiving oxygen via nasal cannula, the admission MDS did not reflect the resident's oxygen use.
Failure to Develop and Accurately Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with chronic respiratory failure and hypoxia. Upon review, it was found that no baseline care plan was present in the resident's medical record. Staff interviews revealed that the responsibility for completing baseline care plans fell to the admitting nurse, especially during weekends. The Director of Nursing noted that computer system changes during a facility acquisition contributed to the issue, but confirmed that the admitting nurse was still responsible for ensuring the care plan was completed. Additionally, the facility did not ensure that a baseline care plan accurately addressed insulin use for a newly admitted resident with diabetes. The baseline care plan for this resident did not indicate the diagnosis of diabetes or the administration of insulin, despite physician orders for insulin therapy. The Admission/Discharge Nurse acknowledged the omission, and both the DON and Administrator confirmed that baseline care plans are expected to accurately reflect residents' diagnoses and medications.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for activities of daily living due to chronic obstructive pulmonary disease, heart failure, and deconditioning, did not receive scheduled showers as required by her care plan. The resident was assessed as having intact cognition and required staff assistance for showering and transfers. Her care plan specified showers twice weekly, on Wednesdays and Saturdays, but documentation and interviews revealed that she did not receive her scheduled Saturday showers for at least three consecutive weeks. The master shower schedule and point of care documentation confirmed the absence of Saturday showers, and the resident reported that staff did not offer alternative hygiene measures, such as a bed bath or hair washing, when a shower was missed. Observations showed the resident with uncombed, greasy hair, and she expressed feeling unclean and uncomfortable due to missed showers. Staff interviews corroborated the resident's account, with one nurse aide confirming the resident did not refuse care and that scheduled showers were not always provided. The Administrator in Training and the Administrator both acknowledged the lack of documentation and confirmed that showers were not given as scheduled. The deficiency was based on the facility's failure to provide care and assistance with bathing for a resident who was unable to perform this activity independently.
Failure to Post Oxygen in Use Signage for Resident Receiving Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary and safety signage outside the room of a resident who was receiving continuous supplemental oxygen therapy. The resident, admitted with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, had a physician's order for continuous oxygen via nasal cannula. Observations on two separate days confirmed that the resident was receiving oxygen through a concentrator, but there was no signage posted outside the room to indicate that oxygen was in use. Interviews with nursing staff and facility leadership revealed a lack of clarity and follow-through regarding responsibility for placing the required oxygen signage. The nurse assigned to the hallway was unaware of the location of the signage, and the DON stated that the admitting nurse or any nurse could place the signage but was unsure why it had not been done. The Administrator also acknowledged that the signage should have been in place but did not know why it was missing.
Unsecured Medications Left at Bedside for Non-Authorized Resident
Penalty
Summary
A deficiency occurred when a resident, admitted with costochondritis and assessed as cognitively intact, was found to have medications stored unsecured at the bedside. The resident had not been approved for self-administration of medications, as documented in the assessment, and physician orders required staff to administer Diclofenac Sodium gel. Despite this, observations revealed a tube of Hydrocortisone cream and a medication cup containing a whitish gel-like substance left in the resident's room. The resident reported using both the Hydrocortisone cream, which was brought by family, and the unidentified gel, which she applied daily for pain but could not name. Staff interviews confirmed that medications should not have been left in the resident's room, as she was not authorized for self-administration. The DON was unable to identify the substance in the medication cup but stated it should not have been present, and nurses on duty denied leaving or noticing the medications at the bedside. The administrator confirmed the expectation that medications be stored appropriately, but the medications remained accessible to the resident in violation of facility policy and professional standards.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
Facility staff failed to follow established infection control procedures when a nurse did not don a gown while administering a tube feeding to a resident who was under Enhanced Barrier Precautions. The facility's policy required staff to wear both gowns and gloves when performing high-contact care activities, such as tube feedings, for residents with devices like feeding tubes. During an observation, the nurse entered the resident's room, which had signage indicating Enhanced Barrier Precautions, washed her hands, and put on gloves but did not wear a gown before administering the tube feeding. When interviewed, the nurse stated she believed a gown was not necessary for tube feeding administration and was unsure if the precautions applied to the resident or the roommate. The Infection Preventionist confirmed that the precautions were for the resident with the feeding tube and that the nurse had previously been educated on the requirements. Facility leadership clarified that staff should assume precautions apply to both residents in a shared room if there is any uncertainty, and that proper PPE should be used as indicated by signage and posted lists.
Failure to Maintain Resident Dignity During Staff Interaction
Penalty
Summary
A deficiency occurred when a nurse aide failed to treat a resident in a dignified and respectful manner. The resident, who had moderate cognitive impairment and required assistance with toileting and transfers, attempted to go to the bathroom unassisted and subsequently fell. Following the fall, the nurse aide engaged in a verbal altercation with the resident, raising her voice, yelling, and arguing with him in the presence of other staff. Witnesses reported that the nurse aide was verbally aggressive, stood over the resident, and was disrespectful and argumentative, which caused the resident to become upset. The incident was corroborated by multiple staff members who observed the nurse aide's behavior. One nurse reported that the aide screamed and cursed at the resident, while another aide described the aide as being snippy, irritable, and raising her voice. The resident was visibly upset by the interaction, and the situation required intervention by a nurse, who instructed the aide to leave the room. After the aide's removal, the resident was assisted back to bed and calmed down. The resident involved had no prior behavioral issues and had recently returned from the hospital, indicating a potentially vulnerable state. The nurse aide admitted in a written statement to raising her voice and acknowledged that the situation could have been handled better. The administrator confirmed that the staff member's conduct was disrespectful and not appropriate, regardless of any personal issues the aide may have been experiencing at the time.
Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A facility failed to protect a resident's right to be free from misappropriation of property, specifically controlled medication. A resident with severe cognitive impairment and diagnoses including depression, anxiety disorder, and dementia had a physician's order for lorazepam to be administered as needed. Two lorazepam pills, which were prescribed for this resident, were discovered in another resident's room by the Administrator in Training (AIT). The AIT reported the finding to a nurse, who took possession of the pills and stated she would waste them after her medication pass. Subsequent review of the controlled medication count sheet revealed that the nurse had signed out two lorazepam tablets for the resident and documented them as wasted, with another nurse signing as a witness. However, interviews revealed that the witnessing nurse had not actually observed the wasting of the medication and acknowledged she should not have signed the sheet. The medication administration record showed that the lorazepam had not been administered to the resident as ordered, and documentation was incomplete regarding the handling and disposal of the controlled medication. The investigation substantiated that the nurse had diverted the resident's medication, as the pills were found in another resident's room and the required documentation and witnessing of medication waste were not properly completed. The involved staff members were no longer employed at the facility at the time of follow-up interviews, and the incident was reported to the appropriate regulatory board.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tsali Care Center | 8.1 mi | ★★★★★ | 0 | 0 |
| Skyland Care Center | 14.7 mi | ★★★★★ | 4 | 0 |
| Vero Health & Rehab Of Sylva | 14.7 mi | ★★★★★ | 0 | 0 |
| Macon Valley Nursing And Rehabilitation Center | 17.5 mi | ★★★★★ | 0 | 0 |
| Graham Healthcare And Rehabilitation Center | 21 mi | ★★★★★ | 6 | 0 |
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