Mountain View Care Center

In the surveyor’s words

From the most serious findings on record at Mountain View Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF725Jun 6, 2025

  Based on resident and staff interviews, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need. Findings include: The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all four quarters in 2024. Per the report, submitted weekend staffing data was excessively low. […]

• No harm, potential for more than minimal, patternF804Jun 6, 2025

  Based on observation, resident and staff interviews, the facility failed to ensure that meals were served at an appetizing temperature for one resident (#46). The deficient practice could lead to nutritional issues and affect residents' quality of life. Resident #46 was admitted on [DATE], with diagnoses that included encounter for other orthopedic aftercare and type two diabetes mellitus with foot ulcer. The review of the resident's admission Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) summary score of 15, which confirms that the resident is cognitively intact. Review of the resident's orders revealed that the resident had an active order, as of December 05, 2023, for a NAS (No added salt) diet, regular texture, regular/thin consistency. […]

• No harm, potential for more than minimal, patternF600Jan 19, 2024

  Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#57) was free from abuse from a visitor, five residents (#116, #59, #126, #112, and #134) were free from abuse from another resident and prevent an injury of unknown origin for one resident (#118). The deficient practice could result in residents being abused. Findings include: Regarding resident #116 and resident #117: -Resident #116 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, necrotizing enterocolitis, anxiety, anemia, gastroesophageal reflux disease, hypertension, dementia with behavior disturbance, fracture of left ulna, fracture of left radius, moderate protein-calorie malnutrition,… […]

• No harm, potential for more than minimal, patternF689Jan 19, 2024

  Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure adequate supervision was provided to prevent resident from wandering into other resident's room for two residents (#57, #116); and, prevent one resident (#129) from elopement. The deficient practice could result avoidable harm to all residents due to lack of adequate supervision. Findings include: -Resident #57 was admitted on [DATE], with diagnoses that included dementia, schizophrenia, major depressive disorder and anxiety disorder. The progress notes dated September 29, 2023 revealed the resident was unable to communicate needs, was monitored for safety, ambulated independently on the hall and wandered in and out of rooms. […]

• No harm, potential for more than minimal, patternF689Jun 9, 2023

  Based on clinical record review, resident interview, staff interviews, and review of facility policies, the facility failed to ensure that three residents (#65, #211 and #11) received adequate supervision to prevent medication accidents. The deficient practice could result in the resident sustaining medication accident-related injuries. Findings include: -Resident #65 Resident #65 was admitted on [DATE] with diagnosis including metabolic encephalopathy, sepsis, polyneuropathy, peripheral vascular disease, non-pressure related chronic ulcer of the left lower leg and type II diabetes with other skin ulcer and skin complications. The MDS (minimum data set) dated March 1, 2023 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. […]