The Villa at Mountain View

In the surveyor’s words

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

• Immediate jeopardy, patternF686Aug 13, 2021

  Based on observations, interviews, and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Resident #1 and Resident #2) of five residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #1 received wound assessments, wound treatments, and on-going skin assessments in that: LVN A did not complete a full skin assessment for Resident #1 when the resident was admitted [DATE] and did not notify the physician or obtain treatment orders for a wound identified on the resident's sacrum on admission. […]

• Immediate jeopardy, isolatedF689May 15, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #154) reviewed for elopements. The facility failed to ensure Resident #154 did not elope from the facility's back door on 04/19/24. Resident #154 was found on the street attempting to go to the gas station across the street from the facility that was located directly off a busy highway. Resident #154 had suffered a skin tear to his arm . The noncompliance was identified as past noncompliance. The IJ began on 04/19/24 and ended on 11/01/24. The facility had corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF689Nov 21, 2024

  Based on record review and interview, the facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision to prevent incidents for two (Resident #1 and Resident #2) of two residents reviewed for elopement. 1. The facility failed to provide Resident #1 and Resident #2 with adequate supervision to prevent each from leaving the building on 11/04/24 around 12:55 AM, when staff were not aware of the elopement until after 6:00 AM, at the start of the next shift. 2. The facility failed to provide Resident #1 with adequate supervision to prevent Resident #1 from removing the Wanderguard and eloping the facility. The noncompliance was identified as past noncompliance. […]

• Actual harm, isolatedF677Mar 14, 2024

  Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADL activity the necessary services to maintain good personal hygiene for 2 (Residents #1, #2) of 9 residents reviewed for ADL care. The facility failed to ensure Resident #1 and #2 were provided timely incontinent care as needed. These failures could place residents at risk of not receiving personal care services, having decreased quality of life, and skin breakdown. Findings include: Record review of Resident's #1s Face Sheet dated 3-13-2024, showed a [AGE] year-old female, with a BIMS (Brief Interview of Mental Status) score of 11, which shows moderate cognitive impairment, who was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Aug 8, 2023

  Based on interview and record, the facility failed to ensure each received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed for accidents and supervision. CNA B failed to use a mechanical lift and obtain assistance from another staff when she transferred Resident #1, resulting in the resident sustaining an injury requiring 3 sutures to his leg during an improper transfer. This failure placed residents at risk for falls or injury during transfers. Findings included: Review of Resident #1's MDS assessment dated [DATE] reflected he dependent on staff for all Activities of Daily Living. Review of Resident #1's Face Sheet dated 07/21/23, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. […]