A list of the most recent deficiencies for Mountain View Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-28 | 2023-05-22 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-22 | 2023-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-22 | 2023-05-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-22 | 2023-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-22 | 2023-05-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-22 | 2023-05-15 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-02-22 | 2023-05-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-22 | 2023-05-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-22 | 2023-05-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-22 | 2023-05-15 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-02-22 | 2023-05-15 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-02-22 | 2023-05-15 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-02-22 | 2023-05-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-22 | 2023-05-15 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-22 | 2023-05-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-22 | 2023-05-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-22 | 2023-05-15 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-02-22 | 2023-05-15 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-02-22 | 2023-05-15 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-22 | 2023-05-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-22 | 2023-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-22 | 2023-05-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-22 | 2023-05-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-07 | 2022-02-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-07 | 2022-02-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-07 | 2022-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-07 | 2022-02-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-07 | 2022-02-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-07 | 2022-02-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-07 | 2022-02-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-07 | 2022-02-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-07 | 2022-02-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-07 | 2022-02-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-07 | 2022-02-21 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-22 | 2022-02-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-02-22 | 2022-02-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-22 | 2022-02-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-22 | 2022-02-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-07 | 2019-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-07 | 2019-12-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-08-07 | 2019-12-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-07 | 2019-11-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-07 | 2019-11-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-07 | 2019-11-20 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-08-07 | 2019-11-20 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-08-07 | 2019-11-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-09 | 2019-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-09 | 2019-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-09 | 2019-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-09 | 2019-09-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-08-09 | 2019-09-23 | N |
