Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain View Post Acute during CMS and state inspections, most recent first.
A resident with acute pulmonary edema and muscle weakness received PT and OT services for 25 days without a physician's order. Therapy assistants conducted sessions, but clinical records lacked documentation of physician authorization or notification. The DON was unaware of the requirement for a physician's order, and the facility had no formal policy to ensure compliance.
A nurse left a computer screen displaying a resident's sensitive medical information unattended and visible in a hallway while administering medication. The resident's record included diagnoses such as fibromyalgia, cardiomegaly, and acute respiratory failure. The nurse admitted to not following proper procedures, and facility leadership confirmed that this action was not in line with policy requiring protection of resident-identifiable information.
A deficiency was identified when an LVN failed to perform hand hygiene after removing gloves following contact with a resident's Foley catheter while the resident was on Enhanced Barrier Precautions. The LVN then shook hands with the resident and left the room without sanitizing hands, contrary to facility policy and infection control expectations as confirmed by the IP and DON.
A resident with a history of muscle weakness and repeated falls experienced an unwitnessed fall, resulting in head stitches. The facility's interdisciplinary team did not review the fall incident as required by the Fall Prevention Program policy, which mandates risk assessment and care plan interventions.
A resident's debit card was misused by the facility's Business Office Manager to pay for the resident's outstanding balance instead of personal necessities like clothing and shoes, as agreed with the bank. The resident had authorized the card for personal expenses, but the funds were used against the bank's terms, potentially neglecting the resident's needs. The facility's policy requires written authorization for fund management, which was not followed, leading to the misappropriation.
A resident with Type 2 DM did not receive Metformin from admission until a month later due to a failure in the facility's assessment and communication processes. The LVN assumed blood sugar checks were for an infection, and the admitting RN did not verify medication needs with the physician, despite the resident's high blood sugar levels.
A facility failed to promptly notify a resident about the Skilled Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMC), leading to a delay in informing the resident's representative about the end of Medicare coverage and appeal rights. The responsible party signed the NOMC form 18 days after coverage ended, contrary to the facility's policy requiring timely notification.
The facility failed to respond to call lights promptly, as reported by two residents with mobility and muscle weakness issues. They experienced significant delays in receiving assistance, contrary to the facility's policy requiring timely responses. Interviews with staff did not yield specific solutions to the residents' concerns.
The facility failed to follow infection control practices, with staff wearing acrylic nails longer than allowed and improper management of urinary catheters for two residents. Acrylic nails were worn by a CNA, the AD, and the IP, contrary to the facility's policy. Additionally, a resident's catheter bag was on the floor, and another's tubing was dragging, both posing infection risks. The DON and IP acknowledged these practices were against the facility's infection control policies.
The facility failed to maintain their walk-in refrigerator and freezer in safe operating condition, leading to potential food spoilage and increased risk for foodborne illness for 42 residents. The equipment was found malfunctioning, with temperatures recorded above acceptable limits, and the facility's policy on maintaining equipment was not followed.
The facility failed to maintain the dignity of two residents by not covering their urinary catheter drainage bags with dignity bags, as required by the facility's policy. One resident with acute kidney failure and another with fournier gangrene were observed with uncovered catheter bags, making the urine visible. The Director of Nursing confirmed the policy requirement for dignity bags to maintain privacy and dignity, which was not followed.
A resident's RAI-MDS was inaccurately coded, failing to indicate a fall since admission, despite evidence from clinical records and resident reports. The MDS nurse responsible acknowledged the error, which stemmed from an incomplete review of available documentation. This oversight had the potential to result in unmet care needs, jeopardizing the resident's health and safety.
A resident with a history of falls and conditions like hemiparesis was found to have only one fall mat instead of the two specified in his care plan. Despite facility policies emphasizing fall prevention, staff acknowledged the oversight, and the Director of Nursing confirmed that care plan interventions were not followed, increasing the risk of injury.
A resident with a history of falls experienced another fall, but the LTC facility failed to conduct a post-fall risk assessment or update the care plan as required by their policies. The DON confirmed that these steps were not taken, despite the facility's protocols mandating such actions after a fall.
A resident with type 2 diabetes was administered insulin Lispro 2 hours before mealtime, contrary to physician's orders, due to an LVN not reading the full order. This error was confirmed by the DON, who noted that facility policies on medication administration were not followed, placing the resident at risk for hypoglycemia.
An IV medication cart was left unlocked and unattended at a nurses' station, containing supplies like syringes and antibiotics. A registered nurse admitted to forgetting to lock the cart, which was against the facility's policy requiring carts to be locked unless in use. The Director of Nurses confirmed the policy was not followed.
Rehabilitative Services Provided Without Physician Order
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services were provided in accordance with federal regulations for one of two sampled residents. A resident who was readmitted with acute pulmonary edema and muscle weakness received both physical therapy (PT) and occupational therapy (OT) services for 25 days without a physician's order. Observations confirmed that the resident participated in PT and OT sessions, including sitting to standing transfers and arm exercises, under the guidance of therapy assistants. A review of the resident's clinical records revealed no documented physician's order for PT or OT treatment, nor any evidence that a physician had been notified about these services. During interviews, the Director of Rehab confirmed the ongoing therapy services, and the Director of Nurses stated unawareness of the regulatory requirement for a physician's order for such services. The facility did not have a formal policy or procedure to ensure physician oversight for rehabilitative treatments.
Failure to Safeguard Resident Confidential Information
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to safeguard a resident's confidential medical information by leaving a computer screen displaying the resident's clinical records unattended and visible in a hallway. The incident occurred when the LVN entered a resident's room to administer medication, leaving the computer with the resident's information accessible to others. The resident's medical record included sensitive information such as diagnoses of fibromyalgia, cardiomegaly, and acute respiratory failure with hypoxia. During interviews, the LVN acknowledged the lapse, attributing it to habit, and the Registered Nurse Supervisor confirmed that staff are expected to close or change the computer screen when stepping away. The Director of Nursing reviewed the facility's policy, which requires that computer screens showing clinical information not be left unattended or visible to unauthorized individuals, and acknowledged that the policy was not followed in this instance.
Failure to Perform Hand Hygiene After Foley Catheter Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to perform hand hygiene after contact with a resident's Foley catheter while the resident was on Enhanced Barrier Precautions (EBP) due to multiple medical conditions, including hypertension, type 2 diabetes mellitus, COPD, protein-calorie malnutrition, and dysphagia. During an observation, the LVN was seen wearing gloves while touching the resident's Foley catheter and bag, then removed the gloves, shook hands with the resident, and exited the room without performing hand hygiene. Interviews with the LVN, Infection Preventionist (IP), and Director of Nursing (DON) confirmed that facility policy requires hand hygiene after glove removal and after contact with devices such as urinary catheters, especially for residents on EBP. The LVN acknowledged the oversight, and both the IP and DON stated that the expectation is for staff to wear appropriate PPE and perform hand hygiene as outlined in facility policies.
Failure to Implement Post-Fall Protocol
Penalty
Summary
The facility failed to implement its post-fall protocol for a resident who experienced a fall on October 23, 2024. The interdisciplinary team did not conduct a review of the fall incident, which was unwitnessed, as required by the facility's Fall Prevention Program policy. This policy mandates that each resident be assessed for fall risk and receive care and services tailored to their individualized level of risk to minimize the likelihood of falls. The policy also requires the nurse and/or interdisciplinary team to initiate interventions on the resident's care plan according to their level of risk. The resident involved in the incident was admitted with diagnoses including muscle weakness, abnormalities of gait and mobility, and repeated falls. During an observation and interview on October 28, 2024, the resident mentioned having fallen recently and receiving stitches on her head as a result. The Director of Nursing confirmed that the interdisciplinary team failed to assess the resident after the fall, which was a deviation from the facility's established procedures.
Misappropriation of Resident's Personal Funds
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their personal funds. The Business Office Manager used the resident's debit card to pay for the resident's outstanding balance at the facility, rather than for personal necessities like clothing and shoes, as was agreed upon with the bank. The resident had given permission for the card to be used for personal expenses, but the Business Office Manager acknowledged using it to cover the resident's past due balance, which was against the terms of the bank agreement. This action was taken despite the resident having the capacity to understand and make decisions, as indicated in their medical records. The facility's policy on managing personal funds requires a written authorization and completion of a Resident Fund Management Service form before the facility can manage a resident's funds. However, the Business Office Manager admitted to using the funds inappropriately, and the Administrator believed the card could be used for the resident's personal costs, including paying off the outstanding balance. This misappropriation of funds had the potential to neglect the resident's personal needs, as the funds were not used for the intended purpose of purchasing personal items like clothing and shoes.
Failure to Administer Diabetes Medication
Penalty
Summary
The facility failed to accurately assess and manage the medication needs of a resident diagnosed with Type 2 Diabetes Mellitus. The resident was admitted with a diagnosis that included Type 2 DM, but from August 11, 2024, until September 12, 2024, the resident did not receive Metformin, a medication necessary for managing their condition. This oversight was discovered during an interview with a Licensed Vocational Nurse (LVN), who stated that the Medication Administration Record (MAR) only indicated a need for blood sugar checks before meals, without specifying the need for Metformin. The LVN assumed the blood sugar checks were related to an infection rather than diabetes management. Further investigation revealed that the registered nurse responsible for the resident's admission was unaware of the need for Metformin until informed by the resident's family. Despite the resident's admission record indicating a diagnosis of Type 2 DM, the nurse did not verify with the physician whether the resident required medication for this condition. A review of the resident's blood sugar summary showed a dangerously high level of 462 mg/dL on August 24, 2024, indicating a lack of proper diabetes management. Metformin was eventually ordered on September 12, 2024, highlighting a significant delay in addressing the resident's medical needs.
Failure to Notify Resident of Medicare Non-Coverage
Penalty
Summary
The facility failed to adhere to its Medicare denial process policy by not promptly notifying a resident about the Skilled Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMC). These documents are crucial for informing the resident about potential non-coverage of services and their appeal rights. The deficiency involved a resident whose responsible party was not informed in a timely manner about the end of Medicare coverage and the appeal process, as required by the facility's policy. The responsible party signed the NOMC form 18 days after the Medicare coverage had ended, indicating a significant delay in communication. The facility's policy, dated October 8, 2018, mandates that Medicare beneficiaries be properly notified when they do not meet the requirements for covered services. However, the review of the facility's documents showed no evidence that the responsible party was informed about the SNF ABN or the appeal process before the termination of Medicare coverage. During an interview, the Business Office Director confirmed that the responsible party was offered the opportunity to sign the forms but only signed the NOMC form well after the coverage had ended. This failure resulted in the resident's representative not being promptly informed of their appeal rights and financial liability for services no longer covered by Medicare.
Failure to Respond to Call Lights Promptly
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely response to call lights, which is crucial for providing care and services to residents. This deficiency was observed in two residents who reported significant delays in staff response to their call lights. Resident 1, who was admitted with abnormalities of gait and mobility and shortness of breath, stated that staff often took up to half an hour to respond to call lights. Similarly, Resident 2, admitted with generalized muscle weakness and a history of repeated falls, reported that staff frequently did not respond when assistance was requested, and it took an excessive amount of time for them to respond to call lights. Interviews with facility staff, including a registered nurse supervisor and the facility administrator, revealed a lack of specific response to the concerns raised by the residents. The facility's policy, revised in December 2022, mandates that staff members who see or hear an activated call light are responsible for responding promptly, and if unable to fulfill the resident's request, they should notify the appropriate personnel. The failure to follow this policy potentially jeopardized the health and safety of the residents involved.
Infection Control Deficiencies in Staff Practices and Catheter Management
Penalty
Summary
The facility failed to adhere to infection control practices as evidenced by staff members wearing acrylic nails longer than the tip of their fingers. Three staff members, including a Certified Nursing Assistant (CNA), the Activities Director (AD), and the Infection Preventionist (IP), were observed with acrylic nails exceeding the permissible length. The facility's Employee Handbook explicitly prohibits artificial nails for staff involved in direct patient care, food services, or medical supply handling, yet this policy was not followed. The Director of Nursing (DON) acknowledged the oversight, confirming that the handbook's guidelines were not enforced. Additionally, the facility did not maintain proper infection control regarding urinary catheter management for two residents. One resident's urinary catheter bag was observed on the floor, and another resident's catheter tubing was seen dragging on the floor. These practices pose a risk of cross-contamination and infection. The Infection Preventionist and the DON both recognized that catheter bags and tubing should not be in contact with the floor, as per the facility's infection prevention policies. The facility's policies, including the Infection Surveillance and Catheter Care procedures, were not adhered to, as evidenced by the observations of catheter management. The DON and IP both confirmed that these practices were not in line with the facility's infection control standards, which are designed to prevent the spread of infections and ensure a safe environment for residents.
Refrigeration Equipment Malfunction
Penalty
Summary
The facility failed to maintain their walk-in refrigerator and freezer in safe operating condition, as both were found to be malfunctioning and unable to maintain acceptable temperatures. On June 10, 2024, during an observation and interview with the Dietary Services Supervisor (DSS), it was noted that the refrigerator and freezer felt like they were at room temperature, and the thermometers had been removed. The DSS confirmed that the equipment had been identified as not working at 4:00 AM that day, having broken sometime overnight. The temperature log for June 10, 2024, recorded the refrigerator at 55 degrees Fahrenheit and the freezer as off, which is above the acceptable temperature limits of not greater than 41 degrees Fahrenheit for refrigeration and not greater than 0 degrees Fahrenheit for the freezer. Further observations on June 11, 2024, with the Registered Dietician (RD) showed the refrigerator at 36.3 degrees Fahrenheit and the freezer at 38.3 degrees Fahrenheit, with the freezer temperatures ranging between 10 degrees Fahrenheit and 35 degrees Fahrenheit throughout the day. A review of the facility's policy on maintaining mechanical and electrical equipment in safe operating condition revealed that the policy was not followed, as stated by the DSS. This failure had the potential to cause food spoilage and increased risk for foodborne illness for all 42 residents receiving food from the facility's kitchen.
Failure to Maintain Resident Dignity with Uncovered Catheter Bags
Penalty
Summary
The facility failed to maintain the dignity of two residents by not covering their urinary catheter drainage bags with dignity bags, as required by the facility's policy. Resident 35, who was admitted with acute kidney failure, metabolic encephalopathy, and obstructive and reflux uropathy, was observed on multiple occasions with an uncovered catheter bag, making the urine visible. This was noted during observations on June 10 and June 13, 2024, with the Infection Preventionist confirming the requirement for dignity bags. Similarly, Resident 500, admitted with fournier gangrene, abnormalities of gait and mobility, and muscle weakness, was found with an uncovered catheter bag during an observation on June 11, 2024. The resident confirmed that the facility did not provide a dignity bag. The Director of Nursing acknowledged that the facility's policy mandates the use of dignity bags to maintain resident privacy and dignity, which was not adhered to in these cases. The facility's policies on promoting resident dignity and catheter care were reviewed, highlighting the requirement for privacy bags to cover catheter drainage bags at all times.
Inaccurate Coding of RAI-MDS for Resident's Fall
Penalty
Summary
The facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for a resident, identified as Resident 33, who was sampled for accidents. The RAI-MDS assessment, dated on an unspecified date, incorrectly indicated that Resident 33 had not sustained any falls since admission, despite evidence to the contrary. Resident 33, who was admitted with diagnoses including hemiparesis and hemiplegia following a cerebral infarction, muscle weakness, and repeated falls, reported having fallen a few weeks prior while in the facility. This was corroborated by a Resident Care Conference Review document dated May 10, 2024, and a physician's progress note dated May 23, 2024, both of which documented a recent fall. The Minimum Data Set Nurse (MDS 1) responsible for completing the RAI-MDS assessment admitted that the section regarding falls was coded incorrectly due to an error. MDS 1 stated that she reviewed the facility's risk management report and progress notes in the resident's clinical record when completing the assessment. However, the risk management report did not indicate any falls, leading to the incorrect coding. The CMS Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's manual specifies that all available sources, including medical records and incident reports, should be reviewed for any falls since the last assessment. The failure to accurately code the RAI-MDS had the potential to result in unmet care needs for Resident 33, potentially jeopardizing the resident's health and safety.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 33, had fall mats on both sides of his bed as specified in his care plan. This deficiency was observed during a survey when it was noted that Resident 33, who had a history of repeated falls and was at risk due to conditions such as hemiparesis and hemiplegia, only had one fall mat on the left side of his bed. The care plan, which was intended to prevent falls and minimize injury, clearly indicated that fall mats should be placed on both sides of the bed. However, during interviews, staff, including a registered nurse, acknowledged the absence of the second fall mat and were unable to explain why the care plan was not fully implemented. The deficiency was further highlighted by a review of the facility's policies and procedures, which emphasized the importance of comprehensive care plans and fall prevention measures tailored to each resident's needs. Despite these guidelines, the facility did not adhere to the specified interventions for Resident 33, potentially increasing the risk of injury from falls. The Director of Nursing confirmed that the care plan interventions were supposed to be followed, yet the oversight persisted, indicating a lapse in the execution of the resident's individualized care plan.
Failure to Implement Fall Prevention Program
Penalty
Summary
The facility failed to implement its fall prevention program for a resident who was reviewed for accidents. The resident, who had a history of hemiparesis, hemiplegia, muscle weakness, and repeated falls, experienced a fall on May 24, 2024. Despite the fall, the facility did not complete a post-fall risk assessment or update the resident's care plan, which was last revised on May 8, 2024. The resident's care plan, which was supposed to be updated after any fall, remained unchanged, indicating a lack of adherence to the facility's policies and procedures. Interviews with the Director of Nursing (DON) revealed that the facility's protocol required a fall risk assessment and an interdisciplinary team meeting after any fall to discuss the incident and implement necessary interventions. However, there was no evidence that these steps were taken for the resident. The facility's policies, dated December 19, 2022, and revised December 28, 2023, clearly outlined the need for a post-fall assessment and care plan updates, which were not followed in this case.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when insulin Lispro was not administered according to the physician's orders. The resident, who was admitted with conditions including type 2 diabetes mellitus with hyperglycemia, was given 2 units of insulin Lispro by an LVN. The LVN administered the insulin 2 hours before mealtime, contrary to the physician's order which specified that the insulin should be given subcutaneously before meals and not sooner than 15 minutes prior. The LVN admitted to not reading the full order, leading to the premature administration of the medication. The Director of Nursing confirmed that the facility's policies and procedures regarding medication administration were not followed. The facility's policy required medications to be administered in accordance with the written orders of the attending physician and within a specific timeframe relative to mealtimes. The failure to adhere to these policies placed the resident at risk for hypoglycemia and potentially jeopardized their health and safety.
Unattended and Unlocked IV Medication Cart
Penalty
Summary
The facility failed to ensure the secure storage of intravenous (IV) medications, as observed when an IV medication cart was left unlocked and unattended at the nurses' station. This cart, used by licensed nurses to transport medications to resident rooms, contained IV supplies, including syringes, needles, and antibiotics. During an observation and interview, a registered nurse (RN) acknowledged that the cart should not have been left open, as it contained residents' information on medication labels and posed a safety risk to ambulatory residents. Further interviews revealed that the RN was the only person with access to the IV medication cart and admitted to forgetting to lock it. A review of the facility's policy and procedure, titled Specific Medication Administration Procedures, indicated that medication carts should be locked at all times unless in use and under direct observation. The Director of Nurses confirmed that the policy was not followed and expressed the expectation that nurses should lock the IV medication cart when not in use.
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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 Barstow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Veterans Home Of California - Barstow | 2.4 mi | ★★★★★ | 2 | 0 |
| Spring Valley Post Acute Llc | 28 mi | ★★★★★ | 7 | 0 |
| Knolls West Post Acute Llc | 29.2 mi | ★★★★★ | 5 | 0 |
| Apple Valley Care Center | 30 mi | ★★★★★ | 15 | 0 |
| Desert Ridge Transitional Care Center, Lp | 30.9 mi | — | 7 | 0 |
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