Mountain View Nursing Home

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF656Aug 2, 2023

  Based on clinical record review, staff interview, and facility document review it was determined that the facility staff failed to implement the comprehensive care plan for one of 14 residents in the survey sample, Resident #7. The findings include: For Resident #7 (R7), the facility staff failed to implement the comprehensive care plan to check functioning of a WanderGuard device (1) used to monitor the resident for elopement. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/1/2023, the resident was assessed as being moderately impaired for making daily decisions. […]

• No harm, potential for more than minimal, patternF658Aug 2, 2023

  Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice for medication administration, for two of 14 residents in the survey sample, Resident #7 and Resident #8. The findings include: 1. For Resident #7 (R7), the facility staff failed to clarify the dosing of an as needed order for the pain medication, Morphine Sulfate (1) oral solution. On the most recent MDS (minimum data set), an admission assessment with an ARD (Assessment Reference Date) of 5/1/2023, the resident was assessed as being moderately impaired for making daily decisions. Section J documented R7 receiving scheduled pain medications during the assessment period. […]

• No harm, potential for more than minimal, patternF689Aug 2, 2023

  Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to monitor the function of Wander Guards used for the prevention of elopements, for two of 14 residents in the survey sample, Resident #7 and Resident #8. The findings include: 1. For Resident #7 (R7), the facility staff failed to monitor the functioning of the WanderGuard device (1) used to monitor the resident for elopement. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/1/2023, the resident was assessed as being moderately impaired for making daily decisions. […]

• No harm, potential for more than minimal, patternF812Jan 27, 2022

  Based on observation and staff interview, it was determined the facility staff failed to store food in a safe and sanitary manner. The facility staff failed to dispose of expired food during an observation on [DATE] at 11:09 AM. The findings include: On [DATE] at 11:09 AM, an observation was conducted in the main kitchen. In the dry storage room, a 4.64 pound bag of dried milk was labeled opened [DATE], use by [DATE]. A 49.6 ounce cornbread stuffing mix bag was labeled opened [DATE], use by [DATE]. OSM (other staff member) #1, a dietary aide, was shown the two bags. When asked what the dates signified, OSM #1 stated, That means that they should be disposed of by those 'use by' dates. […]

• No harm, potential for more than minimal, isolatedF584Oct 9, 2025

  Based on observations and staff interview, facility staff failed to maintain one of 40 resident rooms in homelike condition, resident room [ROOM NUMBER]. The findings include:Facility staff failed to repair a section of wall next to the resident's bed in room [ROOM NUMBER]. On 10/08/2025 at approximately 12:24 p.m. an observation of resident room [ROOM NUMBER] revealed the left side of the bed against the wall. Observation of the wall next to the bed revealed the covering of the sheetrock was torn away in an area approximately 12 inches high by 16 inches wide. On 10/08/2025 at approximately 2:40 p.m. an observation of resident room [ROOM NUMBER] revealed the left side of the bed against the wall. […]