Mountain View Healthcare Center

In the surveyor’s words

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

• Actual harm, patternF622Jul 2, 2024

  Based on interview and record review, the facility (Facility A) failed to permit five of 21 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) to remain at the facility and not transfer to another facility without appropriate reason/s for discharge when: 1. Resident 1 was transferred to Facility B by a facility-initiated discharge (a transfer or discharge which the resident objects to or did not originate through a resident's verbal or written request) without an appropriate reason for discharge in accordance with CFR 483.15(c)(regulation with specific criteria for discharge/transfer of residents). 2. Resident 2 was transferred to Facility B by a facility- initiated discharge without an appropriate reason for discharge in accordance with CFR 483.15(c). 3. […]

• Actual harm, isolatedF694May 7, 2021

  Based on interview and record review, the facility failed to safely monitor the administration of [MEDICATION(S)] in water (D5W) intravenous (IV, tube inserted into a vein) fluid for one of 12 sampled residents (Resident 49) when a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .These failures resulted in Resident 49's fluid overload (too much fluid in the body) which may have caused, or contribute to, Resident 49's deterioration in health, and ultimate death. Findings: Review of Resident 49's undated face sheet indicated she was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF804Nov 16, 2023

  Based on observations, interviews, and review of facility recipes policy, the facility failed to serve food that was palatable and well-seasoned. Specifically, the facility failed to season foods served to residents as required by planned menus. This affected all residents who received food from the kitchen. Findings included: A review of the facility policy titled, Food Palatability Guidelines, implemented on 11/02/2022, indicated, 1. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: a. Providing meals that are varied in color and texture. b. Using spices or herbs to season food in accordance with recipes. c. Serving hot foods/drinks hot and cold foods/drinks cold. d. […]

• No harm, potential for more than minimal, widespreadF880Dec 9, 2022

  Based on observation, interview and document review, the facility failed to implement infection prevention and control practices when: 1. Multiple staff members were not wearing face coverings while in the facility; 2. Two staff members had no documentation of screening for signs and symptoms of Coronavirus 2019 (COVID-19, a contagious [CONDITION(S)] infection that can cause severe respiratory symptoms) before entering the facility; 3. Staff used Sani-Hands Instant Hand Sanitizing Wipes (product intended to sanitize hands) to disinfect furniture in the resident dining room; 4. Staff did not post the necessary signage for a room with droplet precautions (protective measures used to prevent the spread of infection through respiratory droplets); 5. […]

• No harm, potential for more than minimal, widespreadF880May 7, 2021

  Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed when: 1. One staff did not sanitize her hands before donning PPE and entering a resident's room; 2. One staff did not wear the proper personal protection equipment (PPE) when entering multiple residents' rooms in the yellow zone; 3. Visitor screening logs had missing entries for recording temperatures; 4. One staff did not know the correct contact time for a disinfecting product; 5. Two staff did not correctly wear masks in the green zone; 6. A restorative nursing assistant (RNA) did not perform hand hygiene in between tasks; 7. Certified nursing assistant (CNA) G was wearing a facemask with an exhalation valve; 8. […]