Mountain View Health Care

In the surveyor’s words

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

• Actual harm, isolatedF580Sep 9, 2022

  Based on observations, record review, interviews, and policy review, the facility failed to notify the physician for a change in condition for one of two residents (R) (R#41) reviewed for change in conditions. Specifically, R#41 suffered harm as result of staff administering insulin and medications with a sedative effect when resident was difficult to arouse, requiring treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the Change in a Resident's Condition or Status policy, revised May 2017, revealed number 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. […]

• Actual harm, isolatedF658Sep 9, 2022

  Based on observations, record review, interviews, review of job descriptions, policy review, and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to maintain professional nursing standards of quality regarding medication administration. Specifically, Licensed Practical Nurse (LPN) C administered insulin and medications with sedative effects for one resident (R) (R#41) when resident didn't eat breakfast or lunch and was difficult to arouse. In addition, the facility failed to notify the physician for change in condition for R#41. Harm was identified on 9/6/22 when R#41 required treatment with [MEDICATION(S)] for unresponsiveness and opioid overdose in the emergency room . […]

• Actual harm, isolatedF760Sep 9, 2022

  Based on record review, interviews, and policy review, the facility failed to ensure that one resident (R) (R#41) was free from significant medication error. Actual harm occurred when insulin and medications with sedative effects were administered to R#41, who was lethargic and difficult to arouse, resulting in emergency room visit and treatment with [MEDICATION(S)] for unresponsiveness and opioid overdose. The sample size was 31. Findings include: Review of the undated policy titled Medication Incidents and Adverse Reactions revealed 1. In the event of a medication discrepancy, medication error, or adverse medication reaction, immediate action is taken, as necessary, to protect the patient's safety and welfare. 2. […]

• No harm, potential for more than minimal, widespreadF812Jul 12, 2026

  Based on observations, staff interviews, and review of the facility's policies titled, Sanitizing the Ice Machine and Supplies, and Date and Label, the facility failed to appropriately label, date, discard expired food items, and failed to maintain an ice machine under sanitary conditions in one of one kitchen. The deficient practice increased the risk of foodborne illness for 71 residents who received an oral diet from the kitchen.Findings Include:Review of facility's policy titled, Sanitizing the Ice Machine and Supplies dated 02/2025, documented, .If ice is not handled properly, ice can become contaminated and may result in illness and or death. […]

• No harm, potential for more than minimal, widespreadF582Jun 26, 2025

  Based on staff interviews, record review, the facility failed to issue the notice for termination of Medicare Part A benefits, with correct information, for three of three residents (R) (R65, R43, and R131). Findings include: 1. Review of R65's electronic medical record (EMR) titled admission Record located under the profile tab indicated that the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R65's EMR titled significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/8/2024 located in the survey shell, indicated the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15 which revealed the resident was severely cognitively impaired. […]