Mountain View Post Acute

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that rehabilitation services were rendered in accordance with federal regulations for one of two sampled residents (Resident 48), when Resident 48 received physical therapy (PT- a treatment focused on improving movement, mobility, and physical function) and occupational therapy (OT- a therapy aimed at helping individuals perform daily activities and improve functional independence) services without a physician's order. This failure had the potential to result in uncoordinated and ineffective care, which could negatively impact Resident 48's rehabilitation and overall treatment plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard residents' confidential information for one of three sampled residents (Resident 50) when Licensed Vocational Nurse (LVN 4) left the computer screen containing Resident 50's medical information unattended and visible to others on June 4, 2025. This failure resulted in Resident 50's clinical records to be exposed to anyone and had the potential for an unauthorized person to access the information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary and safe environment for one of three residents (Resident 2) on enhanced barrier precaution (EBP - Enhanced Barrier Precautions, infection control measures, specifically focused on reducing the spread of multidrug-resistant organisms (MDROs)) when a License Vocational Nurse (LVN 3) did not perform hand hygiene after contact with Resident 2's foley catheter (a thin, flexible tube used to drain urine from the bladder). This failure had the potential for cross contamination and infection (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) which can jeopardize the health and safety of Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the post fall protocol was implemented in accordance with the facility ' s policy and procedure for one of three residents (Resident 1) reviewed for falls, when the Interdisciplinary Team (IDT ( a group of healthcare professionals from different disciplines working towards a common goal for a resident) did not conduct a review of Resident 1 ' s fall which occurred on October 23, 2024. This failure had the potential for Resident 1 to be at risk of further falls which could increase Resident 1 ' s risk of injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from misappropriation (deliberate misplacement or wrongful use of a resident ' s belongings without consent) of property when Resident 1 ' s debit card was used by the facility Business Office Manager to pay for Resident 1 outstanding balance rather than for Resident 1 ' s personal necessities like clothing and shoes as indicated in the agreement with the bank. This failure had the potential for Resident 1 ' s personal needs not being med and further misappropriation of Resident ' s property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess resident medication and report to physician when one of three sample resident (Resident 1) did not receive medication for Type 2 Diabetes Mellitus (Type 2 DM - a chronic disease that causes high levels of blood sugar) from August 11, 2024, until September 12, 2024. This failure had the potential to jeopardize the health and well-being of Resident 1 who is medically compromised.

Inspectors wroteBased on interviews and record reviews, the facility failed to adhere to its Medicare denial process policy when it did not promptly notify one of three sampled residents (Resident 1) about the Skilled Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: CMS -10055) This document provides information to the patient so they can decide whether or not to get the care that may not be paid for Medicare. Additionally, Resident 1 did not receive timely notification about the Notice of Medicare Non-Coverage (NOMC)which is a notice that a Medicare provider or health plan must give to beneficiaries at least two days before covered services end, along with information on how to request an expedited appeal, as the coverage was coming to an end. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for two of three sampled residents (Residents 1 & 2). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1 & 2) when their requests for assistance with activities of daily living were not responded to promptly.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff followed safe Infection control practices when: 1. Three staff members, one Certified Nursing Assistant (CNA 1), the Activities Director (AD), and the Infection Preventionist (IP), were wearing acrylic nails longer than the tip of the fingers, on June 11, 2024. 2. One resident's (Resident 35) urinary catheter bag (a bag connected to a flexible tube inserted into the bladder and collects urine), was on the floor, on June 13, 2024. 3. One resident's (Resident 33's) urinary catheter tubing (the tubing which connects an indwelling urinary catheter to a urinary drainage bag) was dragging on the floor, on June 11, 2024. These failures had the potential to result in cross-contamination (spread of bacteria) causing serious infections to 42 vulnerable residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure their walk-in refrigerator and walk-in freezer were maintained in safe operating condition when both the fridge and the freezer were identified to not be operating correctly and unable to maintain acceptable temperatures on June 10, 2024. This failure had the potential for food spoilage and increased risk for foodborne illness (illness caused by eating contaminated food) for all 42 residents who received food from the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure dignity was maintained for two of three residents (Resident 35 and 500) when Resident 35 and 500 had their urinary catheter drainage/collection bags (bags which collect and hold urine) not covered with dignity bags (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible). These failures resulted in the urine of both residents (Resident 35 and 500) to be visible to residents and staff within the facility which had the potential to compromise the residents' privacy and feelings of dignity and respect.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for one of one resident (Resident 33) sampled for accidents when the Resident 33's RAI-MDS, dated [DATE], did not indicate the resident sustained a fall since admission. This failure had the potential to result in unmet care needs for Resident 33 which can potentially jeopardize the residents' health and safety.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one of one resident (Resident 33) reviewed for accidents had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) on both sides of his bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident). This failure had the potential for the Resident 33 to sustain a serious injury during a fall in which the severity of the injury may have been lessened if the fall mat had been in place.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement their fall prevention program for one of one resident (Resident 33) reviewed for accidents, in accordance with the facility's policies and procedures when the facility did not complete a post fall risk assessment (an assessment that identify the factors that cause the fall) on Resident 33, and did not review or update Resident 33's care plan (an individualized plan for the medical care of a resident) for falls, after he experienced a fall on May 24, 2024. This failure had the potential for Resident 33 to be at risk for repeated falls and for the facility to not identify potential new causative factors contributing to falls which can cause harm and injury to resident 33.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free of medication errors for 1 of 42 residents (Resident 10) when Resident 10's insulin Lispro (medication to treat high blood sugar) was not given according to physician's orders. This failure placed Resident 10 at risk for hypoglycemia (low blood sugar) and had the potential to jeopardize his health and safety.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure secure storage of intravenous medications (IV - medications administered through the vein) for one of one IV medication cart, (a mobile cart used by licensed nurses to transport medications to resident rooms) when the IV medication cart was unlocked while unattended by license nurse. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 42 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary kitchen in accordance with professional standards for food service safety when: 1) There was diet and grime built on top of the stainless-steel dishwashing machine which had the potential for microorganism growth that could be transferred to the food. 2) Plastic food storage containers were stacked and stored wet, which prevented them from drying and had the potential to allow an environment where microorganisms can begin to grow. 3) There was food, black grime, and trash build-up found behind and, underneath the stove. This had the potential for microorganism growth that could inadvertently be transferred to food. These failures had the potential to cause foodborne illness in a highly susceptible population of 47 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan for one of eight sampled residents (Resident 1) who was on oxygen therapy. This failure had the potential to cause inaccuracy in identifying Resident 1's health care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide clean oxygen tubing when a nasal cannula (NC- a device used to deliver supplemental oxygen to ease breathing) was not changed according to their Oxygen Administration policy for three of three sampled residents (Resident 4, Resident 48, and Resident 102). This failure had the potential to place Resident 4, Resident 48, and Resident 102 at risk for respiratory infection, and inadequate delivery of oxygen due to clogging which could compromise residents' overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food prepared for two of two sampled residents (Resident 16 and Resident 36) on a Pureed Diet (blended to pudding consistency) was not served with a palatable lunch and the taste not comparable to the food served for residents receiving a Regular Diet (diet with no restrictions). This failure had the potential for Resident 16 and Resident 36 to experience a decrease in food intake which could lead to poor nutrition and health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was performed in between resident's care in accordance with infection control standard of practice affecting one of two residents (Resident 19). This failure had the potential for the spread of infection (process of bacteria or viruses invading the body or making someone ill), between residents and staff.