Mountain Villa Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580May 21, 2021

  Based on observation, interview and record review, the facility failed to immediately consult with resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's physician when she had 3 hypoglycemic episodes. After the 3rd hypoglycemic episode, Resident #1 became unresponsive and had no respirations or heart rate. Resident #1 had a DNR and was pronounced dead. This was determined to be past non-compliance immediate jeopardy from [DATE] to [DATE] due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. […]

• No harm, potential for more than minimal, patternF656Dec 4, 2025

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for two residents (Residents #5, and #8) of seven residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #5 to address residents' blood thinner medication prescription, Eliquis. The facility failed to have a comprehensive person-centered care plan for Resident #8 to address residents' diabetes diagnosis. […]

• No harm, potential for more than minimal, patternF940Dec 4, 2025

  Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 1 of 6 facility staff (LVN C) reviewed for trainings consistent with their expected roles, in that; -The facility failed to provide LVN C with training consistent with their expected roles. This failure could place residents at risk of accidents with potential harm due to staff not having up to date training. Findings included: Review of LVN C's personal record revealed annual training by the facility that did not include evidence of training consistent with their expected roles to include Compliance and Ethics, Abuse, Neglect and Exploitation, and Restraint Reduction.In an Interview and Record Review on 12/04/2025 at 2:30 pm with HR… […]

• No harm, potential for more than minimal, patternF550Sep 12, 2024

  Based on observations, interviews, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #3 and Resident #32) reviewed for respect and dignity. The facility failed to ensure staff treated Resident #3 and Resident #32 with respect and dignity, with staff removing residents' trays prior to being completed. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. […]

• No harm, potential for more than minimal, patternF656Sep 12, 2024

  Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #2, Resident #27, Resident #28, and Resident #36) of 13 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #2's comprehensive care plan addressed Resident's code status and fall mat. The facility failed to ensure Resident #27's comprehensive care plan addressed Resident #27's code status and PASRR services. […]