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, isolatedF689Nov 3, 2025

  Based on interview and record review, the facility failed to accurately assess/reassess and provide adequate supervision and safety monitoring for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1, who had moderately impaired cognition and lacked safety awareness, experienced harm when they exited the facility unsupervised, was subsequently found by a bystander outside the facility, lying on the ground and sustained a head injury, left elbow fracture, and multiple bruises that required a hospital evaluation and intervention. […]

• Actual harm, isolatedF600Jan 23, 2025

  Based on interview and record review, the facility failed to ensure a resident was free from neglect for 1 of 3 residents (Resident 1), reviewed for neglect, when they failed to perform consistent skin assessments as ordered and failed to obtain and implement wound treatment orders when Resident 1 developed a new skin concern. Resident 1 experienced harm when they developed a necrotic (death of tissue) area to the right foot and fifth (little) toe which required hospitalization and surgical intervention of a partial amputation of the right foot (side of foot) including the little toe. Findings included . […]

• Actual harm, isolatedF684May 17, 2024

  Based on observation, interview, and record review the facility failed to ensure residents received physician ordered medication, had necessary laboratory values (labs) drawn as ordered, and received timely treatment for abnormal labs for 4 of 4 residents (Residents 1, 2, 3, and 5) reviewed for quality of care. This failed practice resulted in harm for Residents 1 and 2 when their treatment was delayed, conditions worsened, and required hospitalization . Residents 3 and 5 were at risk for their condition to worsen and experience inaccurate or a delay in treatment. Findings included . <Resident 1> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include removal of the left leg below the knee and kidney failure. […]

• Actual harm, isolatedF580Dec 21, 2023

  Based on observation, interview, and record review, the facility failed to notify the provider (physician or nurse practitioner) following a resident's complaint of new onset chest pain for 1 of 2 residents (Resident 22) reviewed for change in condition. The failure to notify the provider in a timely manner resulted in harm to Resident 22 when they experienced distress, delay in treatment, and prolonged pain. Findings included . Review of the facility policy titled, Managing Acute Condition Change (MACC), revised on 02/2018, showed the Resident Care Manager (RCM) or charge nurse would assess the resident experiencing an acute change. The facility would notify the physician and family/responsible party without delay when a change in condition had been identified. […]

• Actual harm, isolatedF684Dec 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure care and services that addressed skin infections and accurate blood pressure treatments were provided in accordance with professional standards of practice for 2 of 5 residents (Residents 44 and 13) reviewed for quality of care. This failure resulted in actual harm to Resident 44 when they experienced unnecessary pain, emotional distress and a decline in their medical condition, and caused unmet care needs and placed Resident 13 at risk for negative health outcomes. Findings included . […]