Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain View Healthcare Center during CMS and state inspections, most recent first.
A resident with severely impaired cognition, dementia, and high fall risk had 1:1 observation discontinued and was later moved to another room, but the DON confirmed there was no written evidence that the RP was notified of either change. The record showed the resident’s daughter was the RP, and facility policy required informing the resident or representative about health status, treatment options, and advance notice of room changes when possible.
Two residents did not receive anti-seizure medications as prescribed due to errors in order entry, timing, and MAR management. For one resident with epilepsy on a lamotrigine titration schedule, the original bedtime order from the hospital was discontinued, a new morning order was entered with a delayed start date, and no lamotrigine doses were documented on two consecutive days; the resident later experienced a seizure during PT and was sent to the hospital. For another resident with epilepsy on lacosamide, two overlapping lacosamide orders were active in the EHR, resulting in administration of the drug three times on one day and four times on the next, exceeding the maximum daily dose; the resident developed dizziness and requested transfer to the hospital. Staff interviews revealed uncertainty about why the lamotrigine timing was changed, that nurses followed the MAR even when duplicate lacosamide orders existed, and that nurses could enter medication orders without oversight, contrary to the facility’s medication administration policy requiring adherence to the six rights and administration as prescribed.
A resident with multiple complex medical conditions was discharged AMA after not returning from a pass, without proper discharge planning, timely notice, or an interdisciplinary team meeting. The facility did not follow its own policies, failed to provide a discharge summary or address the resident's post-discharge needs, and did not ensure safe transition or appropriate placement.
Facility staff did not obtain required signatures from a resident and staff member on the personal effects inventory form at discharge, as mandated by facility policy. The form was left unsigned and there was no documentation of refusal to sign, despite the resident being discharged with personal belongings and the policy requiring signatures to acknowledge receipt of items.
Two residents did not receive required quarterly fall risk assessments, despite one having respiratory disorders and mobility issues and the other having dementia. Both experienced incidents involving falls or near-falls, and the DON confirmed the assessments were not completed as per facility policy.
The facility did not follow physician orders for specialized care and medication administration. A resident's void trial was performed without required urology supervision, leading to complications and transfer to acute care. Additionally, three residents did not receive blood pressure medications as ordered, with doses missed or given inappropriately based on blood pressure readings, as confirmed by the DON.
The facility released medical records of two residents to unauthorized individuals, violating their privacy rights. One resident with dementia had records released to her son, not her designated health care agent. Another resident's records were given to a daughter who was not the substitute decision maker. The DON confirmed these breaches, which contravened the facility's policy on medical record release.
A resident's MDS was inaccurately completed, indicating the use of a walker despite no documentation or observation supporting this. The resident, with conditions including cerebral infarction and morbid obesity, was confirmed by the MDS coordinator and director of rehabilitation to be unable to use a walker due to weakness, violating federal assessment accuracy requirements.
A facility failed to provide a baseline care plan summary to a resident and her representative, as required. The resident, with multiple health conditions, was admitted without the necessary signatures on her care plan, indicating a lack of communication and involvement in her care planning. The DON confirmed the oversight, which contradicted the facility's policy to provide such documentation in an understandable language.
A facility failed to develop a care plan for a resident with morbid obesity, despite it being identified in their assessment. The resident had a BMI of 59.7, indicating severe obesity, but no care plan was created to address this. Interviews with the ADON and DON confirmed the oversight, acknowledging the need for a person-centered care plan as per facility policy.
A facility failed to follow infection control practices when a CNA placed soiled linen on a resident's room floor instead of in a plastic bag, and a janitor walked in the hallway with gloves on, contrary to policy. Both staff members acknowledged their errors, and the infection preventionist confirmed the non-compliance with facility policies.
A bariatric resident with impaired mobility fell off the bed when only one CNA was assigned to reposition her, contrary to the facility's policy requiring two staff members for such residents. The incident highlights a failure to adhere to staffing guidelines, resulting in the resident's fall.
The facility failed to provide proper respiratory care for three residents on oxygen therapy. One resident's BiPAP orders were incomplete, and there was no documentation of oxygen administration or equipment cleaning. Another resident received oxygen without documentation of the liters per minute, and the MAR lacked nurse signatures. The third resident's BiPAP orders did not match hospital discharge orders, and there was no record of equipment cleaning.
A resident with hemiplegia, hemiparesis, and obstructive sleep apnea developed a new productive cough and low blood oxygen levels. A stat chest X-ray was ordered to rule out pneumonia, but it was not performed in a timely manner. The resident was later transferred to the hospital due to increased oxygen needs, highlighting a failure to adhere to the facility's policy for urgent diagnostic services.
The facility failed to comply with CFR 483.15(c) by inappropriately transferring five residents without valid reasons or proper documentation. These facility-initiated discharges were conducted under the false pretense of improved health, despite residents continuing to require long-term care. The transfers led to potential psychosocial harm due to increased distance from support networks.
The facility failed to provide timely written notifications of transfers or discharges to residents, their representatives, and the LTC Ombudsman. Four residents were affected, with notifications made only days before discharge, primarily verbally. The Ombudsman was notified late, hindering advocacy efforts.
The facility exceeded its licensed bed capacity of 123 without approval from the CDPH after an emergency program flex expired. The facility had a total bed count of 136 and a census of 130, with rooms previously used for other purposes converted into resident rooms. Despite submitting an application to increase bed capacity, the facility did not have documented approval, leading to a deficiency noted by surveyors.
Failure to Notify Responsible Party of Care Changes
Penalty
Summary
The facility failed to inform Resident 1’s responsible party when 1:1 observation was discontinued and when the resident was moved to another room. Resident 1 had diagnoses including encephalopathy, dementia, depression, anxiety, difficulty walking, and generalized muscle weakness. His MDS dated 3/11/26 showed a BIMS score of 5, indicating severely impaired cognition, and physician orders dated 2/26/26 stated he was incapable of understanding rights, responsibilities, and informed consent. He was also identified as very high risk for falls, and his daughter was the responsible party for his care. Records and interviews showed that a sitter was assigned to Resident 1 from 4/25/26 through 4/30/26, then discontinued on 5/1/26 because his overall condition had improved and he was placed on regular safety checks. The DON confirmed there was no written evidence that the responsible party was notified before the sitter was discontinued. In addition, the medical record showed Resident 1 was offered and agreed to a room change on 12/4/25, but the DON confirmed there was no written evidence that the responsible party was informed of the room change. The facility policy stated that residents or their representatives should be given advance notice of room changes when possible, and that residents and representatives are to be informed of health status, medical condition, and treatment options.
Failure to Administer Anti-Seizure Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as prescribed and in accordance with professional standards for two residents receiving anti-seizure medications. For the first resident, admitted with epilepsy and on a titration schedule for lamotrigine, the hospital SNF orders dated 10/6/25 directed lamotrigine 25 mg, 2 tablets (50 mg) by mouth at bedtime for 5 days, with a detailed 8‑week up‑titration schedule. The facility’s clinical physician orders initially reflected lamotrigine 25 mg, 2 tablets at bedtime for 5 days, but this order was discontinued on 10/7/25. A new order dated 10/7/25 changed lamotrigine to 25 mg, 2 tablets in the morning for one week, with a start date of 10/8/25 at 9 a.m. The RN documented that admission orders and diagnoses were reviewed with the NP and updated, and the NP’s progress note stated to continue lamotrigine titration as recommended by neurology and to continue all home medications as prescribed by the discharging physician. Review of the medication administration record for this resident showed lamotrigine 25 mg, 2 tablets was given on 10/6/25 at 9 p.m., but there was no documentation of administration on 10/7/25 or 10/8/25. The DON explained that when orders are changed in the EHR, the next dose starts the next day, and that the lamotrigine was scheduled for 10/8/25 at 9 a.m. but was not given because the resident was at therapy; the DON stated medications could be given within one hour before or after the scheduled time, and the resident should have received morning medications between 8 a.m. and 10 a.m. On 10/8/25, PT documentation indicated the resident consented to therapy between 10:15 a.m. and 10:30 a.m., and during use of an Omnicycle, jerky/dystonic movements worsened, therapy was stopped, nursing was notified, and a seizure was identified. A change in condition note documented that at approximately 10 a.m. the nurse went to administer morning medications but the resident was in therapy, and at approximately 10:50 a.m. the therapist reported the seizure, after which 911 was called and the resident was transferred to the hospital. A neurology consult from the hospital recommended facility education regarding the importance of not missing anti‑seizure medications and giving all as prescribed. The RN, NP, MD, DON, and consultant pharmacist each stated they were unsure why the lamotrigine timing was changed, and the consultant pharmacist stated that changes in medication administration timing should be ordered by a provider. For the second resident, admitted with a wedge compression fracture and epilepsy and later readmitted after a hospitalization, the hospital SNF orders dated 10/20/25 specified lacosamide 150 mg, 1 tablet by mouth twice daily, with the last hospital dose given at 9:31 a.m. on 10/20/25. The facility’s physician orders contained two active lacosamide orders: one for 150 mg, 1 tablet by mouth twice a day for seizure starting at 8 a.m. on 10/21/25, and another for 150 mg, 1 tablet by mouth every 12 hours for seizures starting at 9 p.m. on 10/21/25. The MAR showed one lacosamide order scheduled at 8 a.m. and 5 p.m. and another scheduled at 9 a.m. and 9 p.m. The controlled drug record indicated lacosamide 150 mg was correctly given twice daily from 10/11/25 to 10/16/25, but on 10/21/25 it was given once, on 10/22/25 it was given three times, and on 10/23/25 it was given four times at 8 a.m., 9 a.m., 5 p.m., and 9 p.m. Progress notes on 10/23/25 documented that at 6 p.m. the resident complained of dizziness, evening medications were given at 8 p.m., and at 9 p.m. the resident again complained of dizziness and requested transfer to the hospital; 911 was called and the resident was transported. The DON confirmed the multiple lacosamide administrations on those dates. LVNs involved stated they did not remember giving lacosamide twice on the same shift and indicated they followed what was in the MAR. The consultant pharmacist stated the maximum daily dose of lacosamide is 400 mg and that the resident received 600 mg on 10/23/25, described this as an error due to failure to discontinue the first order when the second was entered, and noted that nurses could input orders without oversight. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed, following the six rights of medication administration and comparing the medication source with the MAR, and to administer within 60 minutes before or after the scheduled time unless otherwise ordered.
Failure to Provide Safe and Appropriate Discharge Planning for Resident Discharged AMA
Penalty
Summary
The facility failed to provide sufficient preparation and orientation to ensure a safe and appropriate discharge for a resident who was discharged against medical advice (AMA) after not returning from an authorized pass. The facility did not follow its own policy regarding AMA discharges, as the policy did not support automatic discharge for failing to return from a pass, and staff admitted that the resident did not initiate a request to leave or intend to be discharged. The resident was discharged without timely written notice, and the required discharge notice was not provided in advance or as soon as possible. Additionally, the resident's care plan did not include a discharge plan addressing needs such as medication management, home health referral, or durable medical equipment (DME), and there was no interdisciplinary care team (IDT) meeting to discuss or plan for the resident's discharge needs or placement. The resident had multiple complex medical diagnoses, including polyneuropathy, acute on chronic systolic heart failure, COPD, obstructive sleep apnea, hypertension, and a pacemaker, and required assistance with personal care and supervision for transfers. Despite these needs, the facility did not identify the location of discharge, complete a referral to an appropriate community agency, or provide a discharge summary that included the assistance needed for the resident to adjust to a new living environment. The post-discharge plan of care did not address the resident's limitations or ability to care for himself, and the resident's whereabouts were unknown after discharge. Interviews with facility staff confirmed that the resident was considered discharged AMA solely due to exceeding the allowed hours for being out on pass, despite the facility's policy stating that extended therapeutic leave is not grounds for discharge. The resident was not provided with medications at the time of discharge, only a medication list, and was not given the opportunity to appeal the discharge decision. The facility's own policies required an IDT-developed discharge plan and summary, which were not completed. The lack of proper discharge planning and communication endangered the health and safety of the resident, who was unexpectedly discharged without appropriate preparation, placement, or follow-up care.
Failure to Complete Personal Effects Inventory Documentation at Discharge
Penalty
Summary
Facility staff failed to follow established procedures for documenting a resident's personal belongings at the time of discharge. Specifically, the inventory list of personal effects form, which is used to record a resident's possessions, was not signed by either the resident or facility staff upon discharge. There was also no notation indicating that the resident refused to sign the form. This omission was confirmed during interviews with both a registered nurse and the assistant director of nursing, who acknowledged that the form should have been signed according to facility policy. The resident involved had been admitted with multiple diagnoses, including osteomyelitis, depression, diabetes mellitus, and generalized muscle weakness, and was discharged to an assisted living facility. Review of the medical record indicated that personal belongings were discharged with the resident, but the required documentation acknowledging receipt of these items was incomplete. Facility policy requires both the resident or responsible party and a staff member to sign and date the inventory on admission and discharge, which was not done in this case.
Failure to Complete Quarterly Fall Risk Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two out of three residents reviewed, specifically regarding the completion of quarterly fall risk assessments. One resident, admitted with respiratory disorders and difficulty walking, did not have any quarterly fall risk assessments documented in their clinical record. This resident experienced an incident where they slid down from the commode and ended up on the floor, as noted in a change in condition evaluation. Another resident, admitted with dementia, also lacked a quarterly fall risk assessment during a specified period. This resident was found sitting on the floor next to her bed after attempting to ambulate to the bedside commode and feeling weak. During an interview, the DON confirmed that both residents did not have the required quarterly fall risk assessments completed, as stipulated by the facility's Fall Prevention Program policy, which mandates a fall risk assessment every 90 days and upon changes in a resident's condition. The absence of these assessments meant that the residents' fall risk and prevention strategies were not updated in accordance with their current conditions.
Failure to Follow Physician Orders for Specialized Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services as ordered for several residents. One resident with a history of benign prostatic hyperplasia and obstructive and reflux uropathy was admitted with a Foley catheter and had discharge orders specifying that a void trial should be performed under urology supervision. Despite this, the void trial was conducted at the facility without urology supervision, and the resident subsequently experienced a high post-void residual and discomfort during repeated unsuccessful straight catheterizations, ultimately requiring transfer back to acute care for Foley catheter placement. The director of nursing confirmed that the void trial should have been supervised by urology as per the discharge orders. Additionally, the facility did not administer blood pressure medications according to physician orders for three residents. One resident received hydralazine when their systolic blood pressure (SBP) was below the ordered threshold and did not receive it when their SBP was above the threshold on multiple occasions. Another resident did not receive hydralazine when their SBP exceeded the ordered limit, and a third resident was given losartan potassium despite an SBP below the hold parameter. The director of nursing reviewed the medication administration records and confirmed these discrepancies. Facility policy and job descriptions require that medications be administered according to practitioner orders, which was not followed in these instances.
Unauthorized Release of Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of medical records for two residents by releasing their records to unauthorized individuals. Resident 1, who was admitted with a diagnosis of dementia, had her medical records released to her son, who was only listed as an emergency contact and not her legal representative. The Health Care Power of Attorney for Resident 1 designated her husband as her health care agent, yet the Authorization for the Release of Protected Health Information was signed by her son, with the section for the authorized individual or organization left as 'Not Applicable.' The medical records director confirmed the release of Resident 1's records to her son. Similarly, Resident 2, who was self-responsible with one daughter as a substitute decision maker, had his medical records released to another daughter, who was only listed as an emergency contact. The director of nursing confirmed that the records for both residents were released to individuals who were not their legal representatives, which was against the facility's policy. The facility's policy clearly stated that medical records should only be released to the resident or their legal representative, and the authorization should be reviewed to ascertain access rights.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to accurately assess and complete the Minimum Data Set (MDS) for a resident, which compromised the ability to develop and implement resident-centered care plans and interventions. The resident, who was admitted with diagnoses including cerebral infarction, type 2 diabetes, hypertension, and morbid obesity, had an MDS dated 3/08/24 that inaccurately indicated the use of a walker. The MDS coordinator confirmed that the resident's MDS was not accurate as there was no documentation or observation of the resident using a walker during the specified time frame. Interviews with the MDS coordinator and the director of rehabilitation revealed that the resident was not able to use a walker due to weakness, and there was no supporting documentation in the therapy records. The inaccurate assessment was a violation of federal regulations requiring that assessments accurately reflect the resident's status, as outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to a resident and her representative, which is a requirement to ensure continuity of care and inform them about the initial plan for care and services. The resident, who was admitted with diagnoses including cerebral infarction, type 2 diabetes, hypertension, and morbid obesity, had a baseline care plan effective from early March 2024. However, the plan lacked the necessary signatures from both the resident and her representative, indicating that they were not informed or involved in the care planning process. Interviews and record reviews revealed that the resident's responsible party, her daughter, was not informed about the care plan and did not receive a written summary. The Director of Nursing confirmed the absence of signatures and acknowledged the facility's failure to provide the required documentation. The facility's policy mandates that a written summary of the baseline care plan be provided in a language understandable to the resident and representative, which was not adhered to in this case.
Failure to Develop Care Plan for Obesity
Penalty
Summary
The facility failed to develop and implement a care plan for a resident diagnosed with morbid obesity, despite this being identified in the resident's comprehensive assessment. The resident, who was admitted with multiple diagnoses including cerebral infarction, type 2 diabetes, hypertension, and severe obesity, had a BMI of 59.7, indicating severe obesity. However, a review of the resident's care plans revealed that no care plan was developed to address the obesity diagnosis. Interviews with the assistant director of nursing (ADON) and the director of nursing (DON) confirmed the absence of a care plan for the resident's obesity. Both acknowledged that a care plan should have been developed to address the resident's specific needs related to obesity. The facility's policy on the care and treatment of bariatric residents emphasized the importance of developing a person-centered care plan to ensure the resident's highest practicable well-being, which was not adhered to in this case.
Infection Control Lapses in Linen Handling and PPE Use
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a survey. A certified nursing assistant (CNA) was seen placing soiled linen on the floor of a resident's room instead of in a plastic bag, as required by the facility's policy. During an interview, the CNA acknowledged that the linen should have been placed in a plastic bag. Additionally, a janitor was observed walking in the hallway with gloves on and using a wiper to clean the wall, which is against the facility's policy that states gloves should not be worn in the hallway. The janitor also acknowledged this mistake during an interview. The infection preventionist confirmed that these actions were not in compliance with the facility's infection control policies.
Inadequate Staffing Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safety of a bariatric resident, resulting in an accident where the resident fell off the bed. The resident, who was admitted with a severe obesity diagnosis, had impaired range of motion on one side and required maximal assistance for repositioning in bed. Despite these needs, only one CNA was assigned to reposition the resident, which led to the resident rolling off the bed and onto the floor during a care routine. The assistant director of nursing confirmed that the CNA worked alone with the resident, contrary to the facility's policy that mandates two staff members for bariatric residents. The facility's policy, dated 6/1/23, clearly states that bariatric residents require special care and that adequate staffing is necessary to ensure their safety. The incident occurred because the CNA did not call for additional assistance, as required by the facility's guidelines.
Deficiencies in Respiratory Care Documentation and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents on oxygen therapy. For the first resident, there was no documentation of education on the risks and benefits of refusing to use the BiPAP device. The BiPAP orders were incomplete, lacking specific airway pressures, and there was no record of the amount of oxygen administered. Additionally, a PRN breathing treatment was not administered as ordered, and the resident's respiratory care plan was not individualized. There was also no documentation indicating that the BiPAP was cleaned weekly as per the manufacturer's instructions. The second resident was provided oxygen without documentation of the liters per minute administered. The MAR for May and June did not have nurse signatures indicating the administration of PRN oxygen. The assistant director of nursing confirmed the lack of documentation and stated that the amount of oxygen should be included in progress notes. For the third resident, the BiPAP orders did not match the hospital discharge orders, with the EPAP and IPAP pressures being switched. There was no documentation that the BiPAP was cleaned weekly according to the manufacturer's instructions. The facility's policy required obtaining an order for BiPAP use and settings from a practitioner and following the manufacturer's cleaning instructions, which were not adhered to in these cases.
Failure to Provide Timely Radiological Services
Penalty
Summary
The facility failed to provide timely radiological services for a resident who required a stat chest X-ray. The resident, who had diagnoses including hemiplegia, hemiparesis, and obstructive sleep apnea, developed a new productive cough and experienced an episode of de-saturation. A nurse practitioner was notified of the change in condition and ordered a stat chest X-ray to rule out pneumonia. Despite the urgency of the order, the X-ray was not performed, and the resident was later transferred to the hospital due to increased oxygen needs. The Quality Assurance Director confirmed that the stat order for the chest X-ray was placed but not completed within the expected timeframe of four hours. The facility's policy stated that stat diagnostic orders should be completed as soon as possible, but this was not adhered to in this case. The lack of timely radiological services had the potential to delay necessary treatment for the resident.
Inappropriate Resident Transfers Without Adequate Justification
Penalty
Summary
The facility failed to adhere to the regulations outlined in CFR 483.15(c) regarding the transfer and discharge of residents, resulting in inappropriate facility-initiated discharges for five residents. These discharges were conducted without adequate reasons or proper documentation, as required by federal regulations. For instance, Resident 1 was transferred to another facility without a valid reason, as the facility claimed her health had improved, yet she continued to require long-term care. The social services director admitted to selecting this reason because no other option applied, despite the resident still needing the same level of care at the new facility. Similarly, Resident 2 was transferred under the pretense that her health had improved, although her primary physician was not involved in the decision and assumed the transfer was requested by the resident or family, which was not the case. The facility's documentation did not support the claim that the resident no longer needed the services provided. Resident 3 was transferred without her consent or a documented request from her family, despite being her own responsible party. The facility claimed the transfer was requested by the resident's family, but no evidence was provided to support this claim. Residents 4 and 5 were also transferred without appropriate justification or proper documentation. Resident 4's transfer was allegedly requested by a family member who was not the designated power of attorney, and Resident 5's transfer was initiated by the facility without a selected reason for discharge. In both cases, the residents continued to receive the same level of care at the new facility, contradicting the facility's claim that their health had improved sufficiently to warrant a transfer. These actions led to potential psychosocial harm for the residents, as they were moved to facilities farther away from their support networks, resulting in decreased visits from friends and family.
Failure to Provide Timely Discharge Notifications
Penalty
Summary
The facility failed to provide timely written notification to residents, their representatives, and the State Long-Term Care Ombudsman regarding transfers or discharges. This deficiency was identified for four residents, none of whom received the required 30-day notice prior to their discharge. Instead, notifications were made only a few days before the discharge, primarily through verbal communication, which is not compliant with the regulatory requirements. For Resident 1, the facility did not provide a written notice 30 days prior to discharge, and the notification to the Ombudsman was delayed by six days after the discharge. Similarly, Resident 2 was informed in person rather than in writing, and the Ombudsman was notified 14 days post-discharge. Resident 3 was also notified in person, and the Ombudsman received the notice 24 hours after the discharge. Resident 4's family was informed via phone, and the Ombudsman was notified 29 days after the discharge. The facility's policy and procedure on discharge planning were not followed, as evidenced by the lack of timely written notifications and the absence of documented exemptions from the 30-day notice requirement. The failure to adhere to these procedures deprived residents of their rights to be informed and to appeal the discharge, and it hindered the Ombudsman's ability to advocate on their behalf.
Facility Exceeds Licensed Bed Capacity Without Approval
Penalty
Summary
The facility failed to comply with state regulations by having more residents and/or beds set up for use than the number for which it was licensed, which is 123 beds. This occurred without prior temporary permission or approval from the California Department of Public Health (CDPH) after the expiration of an emergency program flex that had been approved during the COVID-19 pandemic. The facility's Assistant Administrator confirmed during an observation and interview that the facility had a total bed count of 136 and a census of 130, despite being licensed for only 123 beds. The Administrator admitted that the facility had submitted an application to increase their licensed beds to 135, which was still under review, and acknowledged that the facility's census fluctuated above the licensed capacity after the program flex expired. Further investigation revealed that certain rooms, which were previously used for other purposes such as dining and activities, were converted into resident rooms after a change of ownership. The facility's census records indicated that the number of residents exceeded the licensed bed capacity from time to time. Despite having the capacity and staffing for the current census, the facility did not have documented evidence of an approved application for a bed change or capacity increase. This lack of compliance with federal regulations was noted as a deficiency by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mountain View
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Camino Ridge Post-acute | 0.4 mi | ★★★★★ | 2 | 0 |
| Villa Siena | 0.7 mi | ★★★★★ | 0 | 0 |
| Los Altos Post-acute | 0.9 mi | ★★★★★ | 2 | 0 |
| Sunnyvale Post-acute Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Idylwood Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
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