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.

• Immediate jeopardy, patternF805Feb 26, 2025

  Based on observation, record review, resident interview, and staff interview, the facility failed to provide each resident with a nourishing diet in a form prepared to meet their individual needs. This failed practice created an immediate jeopardy sitaution. There was an immediate risk of choking for residents who were supposed to be served mechanical soft diets. This immediate jeopardy situation had the potentail to affect more than an isolated number of residents. Resident identifiers: #86, #42, #36, #48, #19, #57, #53, #16, #60, #75 and #7. Facility census: 106. Findings included: a) During lunch pass, on 02/16/25 at 11:55 AM, Resident #86, #42, #36, and #48 with physician-ordered mechanical soft diets were noted to have whole meatballs and whole penne pasta. […]

• Immediate jeopardy, patternF689Jun 29, 2023

  Based on resident interview, observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #47 expressed to the surveyor he smoked at the facility without staff supervision and kept his own cigarettes and lighter. An interview with the Resident's Licensed Practical Nurse (LPN) #37 confirmed the Resident had asked her earlier in the day to take him out to smoke. The LPN's only response was, you know you are not allowed to smoke. Twenty seven (27) additional residents were identified as lacking capacity and being able to ambulate/wander throughout the facility. […]

• No harm, potential for more than minimal, widespreadF868Jun 29, 2023

  Based on record review and staff interview, the facility failed to ensure the medical director/designee attended quarterly Quality Assessment and Assurance (QAA) meetings. This had the potential to affect all residents that resided at the facility. Facility census: 109. Findings included: a) QAA meetings Review of the QAA sign in sheets, with the Administrator #56 at 2:40 PM, on 06/28/23 found the medical director/designee did not attend any QAA meetings in the first quarter of 2023. Meetings were held on 01/31/23 and 02/22/23. Review of the sign-in sheets found no indication the medical director or designee attended or was present by telephone, zoom, etc during these meetings. A meeting was not held in March 2023.

• No harm, potential for more than minimal, widespreadF880Jun 29, 2023

  39571 Based on observation, staff interviews, and facility documents, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The failed practices were found in the areas of monitoring and prevention of Legionella, establish and implementing a surveillance program, donning appropriate Personal Protection Equipment (PPE) while providing care for residents placed in Enhanced Barrier Precautions, and using proper PPE when entering a Contact Isolation room. These failed practices had the potential to affect more than a limited number of residents who currently reside at the facility. […]

• No harm, potential for more than minimal, patternF584Jun 10, 2026

  Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for two (2) of 58 resident rooms, and the main dining room, observed during the long-term care survey process. Dining room doors in disrepair. Rooms #209 and #210 were in disrepair. Resident Identifiers: #52, 65, 48 and 28. Facility Census: 109. Findings include: a) Hill Valley Healthcare policy titled Homelike Environment states: Residents will be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. […]