Mountain View Health Care

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled, Sanitizing the Ice Machine and Supplies, and Date and Label, the facility failed to appropriately label, date, discard expired food items, and failed to maintain an ice machine under sanitary conditions in one of one kitchen. The deficient practice increased the risk of foodborne illness for 71 residents who received an oral diet from the kitchen. Findings Include:Review of facility's policy titled, Sanitizing the Ice Machine and Supplies dated 02/2025, documented, .If ice is not handled properly, ice can become contaminated and may result in illness and or death. Equally important is to understand steps to sanitizing the ice machine and all other equipment that may meet ice that may potentially contaminate the ice. Review of facility's policy titled, Date and Label dated 01/2026, documented .1. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure that one of 33 sampled residents (R) R70, was free from misappropriation of resident's property. The deficient practice created the potential for other residents to experience misappropriation and negative financial consequences for R 70.

Inspectors wroteBased on record review, resident and staff interviews, and review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, the facility failed to thoroughly investigate misappropriation of resident's property for one of 33 sampled residents (R) R70. The deficient practice increased the risk for other misappropriation.

Inspectors wroteBased on staff interviews, record review, the facility failed to issue the notice for termination of Medicare Part A benefits, with correct information, for three of three residents (R) (R65, R43, and R131).

Inspectors wroteBased on observations, staff interviews, and review of facility policies, the facility failed to ensure staff wore proper hair restraints in the kitchen, ensure proper temperatures of the dishwasher, ensure staff wore gloves during food preparation, ensure food items were dated and discarded on or before expiration dates, ensure sanitary conditions in the kitchen, prevent cross-contamination of food items, and ensure hot food temperatures were monitored and documented, These deficient practices had the potential to place the 77 residents who received meals from the kitchen at increased risks of a foodborne illness.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that essential equipment in the kitchen and laundry room was functioning. Specifically, one reach-in refrigerator in the kitchen, one of two washing machines, and two of three clothes dryers in the laundry were not in operable order. This deficient practice had the potential to affect adequate food production and laundry production in the facility.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Pest Control Policy, the facility failed to ensure the kitchen remained free from pests in one of one kitchen. This failure had the potential to affect the sanitary environment in which food was prepared for 77 residents who consumed food in the kitchen.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Dignity, the facility failed to ensure 34 of 81 residents' meals were served on dinner ware instead of disposable Styrofoam food containers and hydration in disposable cups. The deficient practice had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each residents' quality of life. Review of the facility policy titled, Dignity, with the revised date of February 2021, revealed under Policy Interpretation and Implementation number 5e. provided with a dignified dining experience. Observation on 8/12/2025 at 10:30 am revealed there were 47 eight-inch round plastic re-usable plates on warmers stacked on top of a cart next to the steam table as well as a stack of disposable black Styrofoam hinged-lid food containers. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect three residents (R) (R62, R18, and R40) of four residents reviewed for abuse were free from physical or verbal abuse out of 37 total sampled residents. Specifically, R62 was physically abused by R6, and R18 and R40 were verbally threatened by R6.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Abuse Investigation and Reporting, the facility failed to report an allegation of verbal abuse to the State Survey Agency (SSA) within two hours for two of three residents (R) (R18 and R40) reviewed for abuse out of a total sample of 37. Specifically, R6 verbally abused R18 and R40.

Inspectors wroteBased on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two of 37 sampled residents (R) (R65 and R20) had an accurate Minimum Data Set (MDS) assessment. This deficient practice had the potential to place R65 and R20 at risk of inaccurate care plans and not receiving care according to their needs.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled Falls and Fall Risk, Managing, the facility failed to conduct a thorough and accurate fall investigation for one of four residents (R) (R41) reviewed for falls. This failure had the potential to place R41 at risk of further falls.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure adequate interventions were provided to establish proper nutrition for gradual weight loss for one of six residents (R) (R38) reviewed for nutrition. This placed the resident at risk for further weight loss.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure one of one resident (R) (R44) reviewed for respiratory services received oxygen as ordered by the physician out of a total sample of 37 residents. This failure placed the resident at risk of receiving insufficient oxygen to meet the assessed respiratory need.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Bed Safety and Bed Rails, the facility failed to ensure three of 37 sampled residents (R) (R78, R38, and R41) were appropriate for the use of quarter side rails on their beds. This failure had the potential to place R38 and R41 at risk for injury related to potentially unnecessary side rail use.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policies titled Administering Medications and Hypertension- Clinical Protocol, the facility failed to ensure two of five residents (R) (R23 and R35) reviewed for unnecessary medications were free from significant medication errors. Specifically, when R23 did not receive glargine (insulin medication) on four occasions, Novolog (insulin medication) on five occasions, and hydralazine (blood pressure medication) on three occasions, and when blood pressure medication was not held according to the physician's order for a low blood pressure for R35. These failures had the potential to place R23 and R35 at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observation, staff interview, review of manufacturer package insert, and review of the facility policies titled Medication Storage in the Facility and Administering Medications, the facility failed to discard an expired insulin vial for one of three medication carts and failed to monitor the temperatures of one of one medication storage refrigerators. The deficient practice could result in decreased or altered effectiveness of the medication and worsening of the resident's symptoms.

Inspectors wroteBased on observations, resident and staff interviews, record review, recipe review, and review of the facility's policies titled Standardized Recipes and Preparing Pureed Foods, the facility failed to ensure recipes were followed to ensure the food was palatable for four of 37 sampled residents (R) (R60, R56, R45, and R25). This failure had the potential to place R60, R56, R45, and R25 at risk of decreased oral intake and weight loss.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Administering Medications, the facility failed to ensure infection control was maintained for one of three residents (R) (R68) observed during medication administration. Specifically, the facility failed to ensure medications were not touched with bare hands or dropped during medication administration, which increased the risk for cross-contamination and infection.

Inspectors wroteBased on observation, staff interviews, and review of the facility's policies titled, ''Date Marking for Food Safety'' and ''Food Safety Requirements,'' the facility failed to date, label, and/or cover food, and discard food with expired expiration dates or signs of spoilage stored in the facility's kitchen and the facility's ''Diet Room.'' Additionally, the facility failed to serve [NAME] stew from the kitchen's tray line at an internal temperature of 135 degrees Fahrenheit (F) or higher. This failure had the potential to affect all 67 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of the facility's policies titled, ''Resident Dining, and Promoting/Maintaining Resident Dignity the facility failed to provide care and services in a manner to ensure a dignified existence for six of six residents (R) (R64, R118, R11, R50, R31, and R47) reviewed for dignity. Specifically, the facility failed to promote a dignified dining experience by serving desserts and beverages in disposable bowls and cups and serving disposable plastic eating utensils at meals for four of four residents (R64, R118, R11, and R50) reviewed for dignity while dining. Additionally, the facility failed to assist and encourage R31 and R47 to dress in clothes other than a hospital gown.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to protect the resident's right to be free from verbal and sexual abuse for one of five Residents (R) R52 by R219. Specifically, the facility failed to intervene after multiple incidents of verbal sexual abuse towards female residents by R219, that resulted in physical sexual touching towards R52, who was a target of prior verbal abuse by R219.

Inspectors wroteBased on observations, record review, staff interviews, and review of facility's policy titled, ''Restraint Free Environment Policy,'' the facility failed to ensure one of one Resident (R) (R4) reviewed for physical restraints was free from an unnecessary physical restraint. Specifically, R4 did not have the necessary consent or an assessment in place for seatbelt to be applied and used with use of wheelchair.

Inspectors wroteBased on record reviews, staff interviews, and review of the facility's policy titled, Abuse, Neglect, and Exploitation,, the facility failed to ensure that an allegation of verbal abuse was reported immediately, but no later than two hours of the alleged verbal abuse for two of six Residents (R) (R31, and R218) reviewed for resident-to-resident abuse.

Inspectors wroteBased on record reviews, staff interview, and review of the facility's policy titled, Abuse, Neglect, and Exploitation the facility failed to ensure a thorough and complete investigation was conducted following a resident-to-resident altercation, involving two of six Residents (R) (R7 and R9) reviewed for alleged abuse. This failure not to conduct a thorough abuse investigation had the potential to result in other residents not being identified as potential victims of abuse. Findings Include: Review of the facility's policy titled Abuse, Neglect, and Exploitation dated 2017, stated .7. Investigation of Alleged Abuse, Neglect, and Exploitation- When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur, an investigation is immediately warranted. [...]

Inspectors wroteBased on record reviews, staff interviews, and review of the facility's policy titled, ''Comprehensive Care Plans,'' the facility failed to ensure two of 26 Residents (R) (R11 and R219) reviewed for care plans had a complete and comprehensive care plan. Specifically, R11 care plans did not address the resident's prescribed psychotropic medication problem area and/or interventions. Additionally, R219 known inappropriate sexual behaviors was not identified on the resident's care plan.

Inspectors wroteBased on observations, record review, staff and resident interviews, and review of the facility's policy titled, ''Activities of Daily Living (ADLs) Policy,'' the facility failed to ensure one of three Residents(R) (R56) reviewed for Activities of Daily Living (ADLs) received ADL assistance according to his plan of care. Specifically, staff did not ensure the resident received consistent nail care.

Inspectors wroteBased on observations, record reviews, staff interviews, and review of the facility's policy titled, ''Activities Policy the facility failed to ensure three of four Residents (R) (R17, R31, and R47) reviewed for activities were provided with an activities program to meet their individual needs. Specifically, staff did not ensure residents who were room and/or bed bound were provided with consistent activities.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policy titled, ''Catheter Care Policy,'' the facility failed to ensure consistent infection control for one of three Residents (R) (R56) reviewed for urinary catheters. Specifically, staff failed to ensure sanitary maintenance of the resident's catheter bag and tubing.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, ''Food Safety Requirements,'' the facility failed to maintain and ensure the kitchen's three door reach-in freezer operated at zero degrees Fahrenheit (F) or below for safe food storage for one of two freezers used to store food.