Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% worse than Nevada average
Nevada average: 7.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 8
Date: Nov 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, nutrition, equipment maintenance, and food safety at Mountain View Care Center.
Findings
The facility was found deficient in multiple areas including failure to develop timely baseline and comprehensive care plans for residents, improper catheter care, inadequate monitoring of resident weights and hydration, incomplete delivery of tube feeding orders, unsanitary kitchen conditions, improper infection control practices including reuse of gowns without proper policy, and failure to maintain essential kitchen equipment in good repair.
Deficiencies (8)
Failed to develop a baseline care plan for the use of an indwelling Foley catheter within 48 hours of admission for Resident 82.
Failed to develop and implement a comprehensive care plan for fall prevention and medication self-administration for Residents 56 and 79.
Failed to ensure Resident 82's Foley catheter was properly assessed and the correct size was inserted or clarified.
Failed to monitor weights for Resident 67 with prescribed weight gain and ensure tube feeding free water flush orders were followed for Resident 11.
Failed to ensure tube feeding orders were followed and completely delivered as ordered for Residents 54, 48, and 11.
Failed to label and date open stored food products and maintain sanitary conditions in the kitchen.
Failed to ensure signage for Enhanced Barrier Precaution was posted, PPE was available, gowns were used by staff during direct care, hand hygiene was performed after glove removal, and a policy was in place regarding reuse of gowns.
Failed to maintain essential kitchen equipment in good repair, including ice machine and freezer thermometer, risking food safety.
Report Facts
Residents sampled: 20
Weight records: 3
Weight loss percentage: 7
Water deficit: 209
Tube feeding formula deficit: 654
Tube feeding volume deficit: 366
Tube feeding volume deficit: 403
Temperature readings: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed no care plan for Resident 82's Foley catheter and acknowledged care plan discrepancies |
| Unit Manager | Unit Manager | Confirmed no care plan for Resident 82's Foley catheter and noted order not followed |
| Licensed Practical Nurse | Licensed Practical Nurse | Verified Foley catheter size discrepancy for Resident 82 |
| Registered Dietitian | Registered Dietitian | Acknowledged weight monitoring deficiencies and tube feeding order discrepancies |
| Nurse Manager | Nurse Manager | Explained fall risk assessment and care plan requirements for Resident 56 |
| Hospice Registered Nurse | Hospice Registered Nurse | Provided care to Resident 82 without gown due to lack of signage and PPE availability |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Did not wear gown or perform hand hygiene after glove removal during care of Resident 63 |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Did not wear gown during care of Resident 63 |
| Wound Care Treatment Nurse | Wound Care Treatment Nurse | Acknowledged reuse of gowns and risk of cross-contamination |
| Director of Environmental Services | Director of Environmental Services | Confirmed availability of washable gowns and laundry capacity |
| Infection Preventionist | Infection Preventionist | Confirmed no policy on reuse of gowns after use |
| Nurse Practitioner | Nurse Practitioner | Unaware of incomplete tube feeding administration for Resident 48 |
| Kitchen Manager | Kitchen Manager | Acknowledged unsanitary kitchen conditions and equipment issues |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging neglect of a dependent, non-verbal resident who was left in a wet brief for an extended period of time.
Complaint Details
Complaint NV00071456 was substantiated with multiple residents confirming neglect. The employee of concern was suspended on 05/10/2024, terminated on 05/15/2024, and reported to the licensing board.
Findings
The facility failed to ensure proper care for Resident 1, who had severe cognitive impairment, resulting in neglect by a Certified Nursing Assistant. The employee was terminated following investigation and multiple residents confirmed neglect allegations. The facility implemented corrective actions including staff education and new documentation procedures.
Deficiencies (1)
Failure to protect a dependent, non-verbal resident from neglect by leaving the resident in a wet brief for an extended period.
Report Facts
BIMS score: 3
Residents interviewed: 5
Residents confirming neglect: 3
Inspection Report
Routine
Deficiencies: 7
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, respiratory care, food safety, and staff training at Mountain View Care Center.
Findings
The facility was found deficient in several areas including failure to develop and implement person-centered care plans for residents with limited English proficiency, failure to carry out physician orders for splint use and oxygen administration, failure to obtain physician orders for medication administration, improper labeling of medications, expired food items in the kitchen, and inadequate staff training on language line services.
Deficiencies (7)
Failed to ensure a person-centered care plan was developed and implemented for a resident with limited English proficiency (Resident 74).
Failed to ensure a physician's order for a splint device was carried out for a resident (Resident 46).
Failed to ensure a physician order for continuous use of Oxygen was followed for a resident (Resident 53).
Failed to ensure a physician's order was obtained in the administration of a medication for a resident (Resident 10).
Failed to ensure a multi-dose Insulin pen stored in medication cart was dated when opened.
Failed to ensure items in a refrigerator were not expired and food in the freezer was labeled and dated.
Failed to ensure training was provided to employees regarding the facility's language line or interpretation services for residents with limited English proficiency.
Report Facts
Residents sampled: 19
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts inspected: 3
Languages available: 36
Languages available: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Confirmed lack of communication boards and use of translator app for Resident 74 |
| Director of Nursing | Director of Nursing (DON) | Confirmed deficiencies related to Resident 74, Resident 46, Resident 53, Resident 10, and medication labeling |
| Director of Rehabilitation Services | Director of Rehabilitation Services (DOR) | Discussed splint device use and communication with Occupational Therapist for Resident 46 |
| Occupational Therapist | Occupational Therapist (OT) | Discussed splint device refusal and re-evaluation for Resident 46 |
| Assistant Administrator | Assistant Administrator | Confirmed therapy staff responsibility and communication failures for Resident 46 |
| Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Reported limited communication with Resident 74 and unfamiliarity with language services |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Administered medication to Resident 10 without physician order and commented on oxygen flow rate for Resident 53 |
| Kitchen Manager | Kitchen Manager | Reported expired milk and unlabeled food items in kitchen |
| Director of Staff Development | Director of Staff Development (DSD) | Acknowledged lack of training on language line services |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity during meal assistance, respect and dignity in staff interactions, maintenance of equipment and environment, grievance process, care planning for seizure disorders, CPR certification for staff, use of safe equipment, respiratory care, medication storage and labeling, dietary staffing and food temperature, infection prevention including PPE use and N95 fit testing, and influenza vaccination administration.
Deficiencies (13)
Staff member was observed standing while assisting a resident with their meal, failing to maintain dignity.
Facility failed to ensure residents were treated with dignity and respect; staff used profanity around residents.
Wheelchair was not maintained in good operating condition; light fixture needed repair; window in resident room was defective.
Facility failed to follow grievance process and did not provide response to residents regarding concerns.
Care plans were not completed or up to date for residents with seizure disorders.
Eight employees lacked current CPR certification.
Hoyer slings in use were torn or damaged, posing risk of injury to residents.
Oxygen cannula tubing and humidifier bottles were not changed weekly as required, risking respiratory infections.
Medication room was not kept clean; expired biologicals and medications of discharged residents were present; insulin pens were not dated; Tubersol vial was not discarded after 30 days.
Dietary staffing was inadequate resulting in delayed meal service and cold food being served.
Hot foods were not served at a palatable temperature, causing resident dissatisfaction.
Staff failed to don appropriate PPE prior to entering COVID-19 rooms; N95 fit testing was not completed for many employees.
Facility failed to provide influenza vaccination to 61 of 78 residents requesting it.
Report Facts
Residents requesting influenza vaccine: 62
Residents not vaccinated: 61
Employees without current CPR certification: 8
Residents affected by dietary staffing issue: 70
Residents affected by cold food: 11
Minutes late for meal delivery: 45
Torn or damaged Hoyer slings: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #12 | Named in findings related to use of profanity and disrespectful behavior toward residents | |
| Director of Nursing | DON | Interviewed regarding grievance process, care plans, CPR certification, infection control, and medication storage |
| Assistant Director of Nursing | ADON | Interviewed regarding meal service, oxygen care, and infection control |
| Maintenance Director | MD | Interviewed regarding wheelchair, light fixture, and window maintenance |
| Dietary Manager | DM | Reported on meal service delays and food temperature issues |
| Certified Nursing Assistant | CNA | Observed and interviewed regarding PPE use and meal service |
| Registered Nurse | RN | Interviewed regarding oxygen care and infection control |
| Central Supply Clerk | Interviewed regarding N95 mask supply and fit testing | |
| Director of Human Resources | Interviewed regarding CPR certification |
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