Mountain View Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF686Nov 16, 2023

  Based on observations, record review and interviews the facility failed to ensure two (#93 and #62) of three out of 51 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure: Resident #93, who was at high risk for developing pressure wounds and an increased risk for developing infections, developed a sacral skin wound on 5/25/23 that progressed to a stage 4 sacral pressure wound. The facility failed to ensure effective and timely interventions were in place to prevent Resident #63 from the development of pressure wounds. The facility failed to assess, monitor and document skin assessments and pressure wounds. […]

• Actual harm, isolatedF692Nov 16, 2023

  Based on observations, record review and interviews the facility failed to ensure for four (#75, #79, and #111) of five residents reviewed received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being, out of 54 sample residents. Specifically, the facility failed to follow physician orders for significant weight loss, consistently put interventions in place and timely address Resident #75 nutritional needs. Specifically, the facility failed to follow physician orders for weight loss, consistently put interventions in place and timely address Resident #79 nutritional needs. Resident #75 experienced a significant, unplanned weight loss of 12 % in three months. […]

• Actual harm, isolatedF689Mar 2, 2023

  Based on observations, record review and interviews, the facility failed to prevent an accident involving hot liquid which caused a second degree burn with one (#1) of three out of 13 sample residents. On 1/21/23 at 2:45 p.m. Resident #1 was found to have a large blistered and reddened area on the right thigh. Nursing staff were unable to explain how the injury occurred. A physical assessment and investigation was initiated. Nursing staff revealed the resident was assessed to have two burn sites on the right thigh. The resident was experiencing pain at the burn site (see more information below). On 1/24/23, the resident was examined for an initial evaluation with a wound care physician. The physician diagnosed the resident with a second-degree burn to the upper right thigh. […]

• Actual harm, isolatedF684Apr 22, 2021

  Based on observation, record review and interviews, the facility failed to provide treatment and care services in accordance with professional standards of practice for one resident (#3) of three residents reviewed for change of condition out of eight sample residents. The facility failed to ensure timely care and services were provided to Resident #3 following a change of condition. Resident #3 suffered three falls within six days in December 2020 after she recovered from COVID-19 with an increase in behavioral symptoms. The falls occurred during the night shifts on 12/14/2020, 12/16/2020, and 12/19/2020. The resident experienced new pitting [CONDITION(S)] to the lower left extremity and a noticeable increase in reported pain levels starting 12/21/2020. […]

• No harm, potential for more than minimal, widespreadF812Dec 11, 2025

  Based on observations and interviews the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and three of three nourishment rooms. Specifically, the facility failed to:- Ensure employees performed hand hygiene appropriately;- Ensure food was labeled, dated and stored appropriately; - Ensure dishes were washed and sanitized at the correct temperature,- Ensure equipment was stored properly; and,- Ensure the nourishment room refrigerators were clean and maintained at safe temperatures. Findings include:I. Ensure employees performed hand hygiene appropriatelyA. […]