Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Post Acute during CMS and state inspections, most recent first.
A resident with a history of trauma and recent bilateral amputations was in the activities room with others when another resident, who had a behavior care plan for verbal aggression and mood disorder, began talking loudly. After being told to calm down, the verbally aggressive resident responded with racial and sexual orientation insults and struck the other resident in the face with an open hand, while no staff were present in the room. A witness reported that it took a long time for staff to arrive and that the resident who was hit had already left by the time staff came. The aggressive resident’s prior care plan called for monitoring behaviors and intervening before agitation escalated, yet the incident was not documented in that resident’s progress notes, even though facility leadership later substantiated the event as abuse.
Sanitation, labeling, temperature control, and hand hygiene failures in food service: Staff handled utensils and resident meals without proper hand hygiene, including glove misuse and interrupted resident feeding. Surveyors found multiple unlabeled or undated foods, cold foods held above safe temperatures, a dish machine operating at 104 F with incomplete logs, wet pans stacked for storage, and nourishment refrigerators/freezers with food debris, spills, stains, and crumbs.
Failed Shower Room Ventilation: Surveyors found that four of four resident shower rooms lacked functioning outside ventilation. The fan outlets in all four rooms were without a motor, one unit had no window or mechanical ventilation, and one outlet had no switch to operate it. A tissue test showed the vents did not function, and the MTD confirmed the exhaust fans were not working.
Surveyors found that multiple rooms lacked clean washcloths, had broken or missing towel racks, and were not properly cleaned. One resident's room had a broken window seal that allowed ants to enter, and a main shower room had a hazardous, dangling light fixture with exposed wires. Staff interviews confirmed that towels were only provided upon request and that maintenance issues were not promptly addressed.
Meal service was delayed and disorganized in two dining rooms, with residents waiting past the posted meal time, receiving no timely explanation, and being served at the same table at different times. In one dining room, cold food items delayed service further, while residents waited without drinks, snacks, or diversion and repeatedly asked staff what was happening. Trays were passed out in a random order, leaving tablemates to eat separately and some residents waiting while others had already finished.
Failure to Provide Individualized Activity Programs: Several residents with dementia, brain injury, and other serious conditions were repeatedly observed without meaningful activity, despite documented preferences for music, reading, group events, animals, going outside, and social interaction. Staff did not consistently invite residents to activities, provide one-to-one engagement, or document ongoing participation, and one resident reported she was not informed about activities she would have wanted to attend.
Beds were left elevated to about four feet on the secured unit for multiple residents, and one resident was observed climbing into a high bed and sitting with legs dangling until a CNA lowered it. Staff said the beds were kept up so residents would not self-transfer or use them, but the ADON acknowledged that elevated beds were an accident hazard.
Incomplete CNA Annual In-Service Training: The facility failed to ensure three of five CNAs reviewed completed the required 12 hours of annual in-service training, including dementia management and abuse prevention content. Record review showed the CNAs did not have the required training hours, and the staff development coordinator stated she was responsible for ensuring compliance but did not have a timeline for checking staff competencies.
Two residents with severe cognitive impairment and behavioral disturbances engaged in a physical altercation in a common area, resulting in a skin tear to one resident. Despite documented care plans and staff awareness of their aggressive behaviors, the facility did not effectively prevent the incident, constituting a failure to protect residents from abuse.
Housekeeping staff did not consistently follow infection control protocols, including proper hand hygiene and glove changes between tasks, and failed to disinfect high-touch surfaces and reusable cleaning equipment. These lapses led to recontamination of cleaned areas and improper handling of resident personal items, contrary to CDC guidelines and facility policy.
Failure to inform a cognitively intact resident of the risks of refusing nutritional supplements. The resident had multiple serious diagnoses, was dependent for ADLs, and had significant weight loss with poor intake, including refusal of meals and supplements. Staff and the record showed ongoing weight loss and repeated refusals, but there was no documentation that the resident was educated on the possible effects of continued noncompliance with the nutritional plan.
Failure to Follow Up on Cataract Surgery and Vision Services: A resident with dementia, dry eye syndrome, and significant vision difficulty reported that she could not see out of one eye and had been told she needed cataract surgery, but the facility did not ensure the surgery was scheduled after the eye appointment and testing were completed. Record review and staff interviews showed the SSA, scheduler, and DON team knew follow-up was needed, yet no timely coordination with the eye care center was documented.
The facility's call light system was not fully functional, with alarms only audible at the nurse's station and visual indicators obstructed by the building layout. Multiple residents experienced long waits for assistance, including urgent medical needs, due to staff being unable to hear or see call light alerts when away from the nurse's station. Staff confirmed the system did not indicate which resident had called first or how long calls had been active, resulting in delayed responses to resident care needs.
A resident with multiple chronic conditions did not receive medications, including Baclofen, Eliquis, and Gabapentin, within the prescribed time frames on numerous occasions. Most late administrations were by an LPN, with some doses given hours late or in close succession, disrupting consistent therapeutic management. Staff cited high resident acuity and workflow challenges as contributing factors, and the DON was unaware of the frequency of late doses until an audit was performed.
A resident with mental disorders and psychosocial adjustment difficulties did not receive appropriate treatment and services in the facility. Despite having a care plan, the resident's distress and aggressive behaviors were not effectively managed or documented. The facility failed to provide necessary psychiatric or psychological support, and the resident was not reviewed in psychoactive drug meetings. Staff interventions were limited, and there was a lack of follow-up from social services.
The facility failed to maintain a system for reconciling and destroying controlled substances, resulting in a large inventory of medications awaiting destruction. The DON admitted to not having a system in place for tracking discontinued medications, and the NHA was unaware of the issue. The facility's pharmacist had not completed reconciliation monitoring.
A resident with cognitive intactness and multiple health conditions, including diabetes and benign prostatic hyperplasia, experienced a significant delay in receiving incontinence care, waiting nearly three hours for assistance. The resident frequently faced long wait times for care, particularly on weekends, and expressed frustration over the issue. Staff interviews revealed inconsistencies in the frequency of incontinence checks, with some staff indicating checks should occur every two hours, while others noted variability based on the resident's needs. The facility's policy required timely assistance for residents unable to perform ADLs independently, but adherence to this policy was lacking.
A facility failed to provide proper treatment and medication administration for three residents. One resident did not receive wound care as ordered, another had issues with surgical site care, and a third faced medication shortages affecting pain management. Staff interviews revealed documentation and communication issues contributing to these deficiencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) effectively, as observed when a CNA did not perform hand hygiene or wear PPE before providing care to a resident with a chronic wound. Staff interviews revealed inconsistent understanding and application of EBP protocols, with some staff not wearing PPE during required interactions. The infection preventionist noted ongoing training efforts, but adherence failures persisted, compromising infection control standards.
Failure to Prevent Resident-to-Resident Physical Abuse in Unsupervised Activities Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in the activities room. On the evening in question, one resident with a history of trauma and recent bilateral above-knee amputations was in the activities room with other residents when another resident, who had a behavior care plan for verbal aggression, began talking loudly. The first resident told him to calm down or stop talking, which led to the second resident responding with racial and sexual orientation insults and then striking the first resident in the face with an open hand. The first resident reported that he grabbed the other resident’s shirt during the confrontation and then turned around and left the room. At the time of the incident, there were no staff members present in the activities room. A witness resident confirmed that the verbally aggressive resident was talking too much and too loudly, that the other resident told him to calm down, and that the verbally aggressive resident overreacted, insulted him, and hit him in the face. The witness also stated that there were no staff in the room and that it took a long time for staff to arrive, by which time the resident who had been struck had already left the room. The assistant director of nursing later learned of the altercation only after hearing someone scream for a nurse and then went to check on the residents. The resident who committed the physical act of abuse had documented diagnoses including depression and an unspecified mood (affective) disorder, and an existing behavior care plan initiated months earlier for a history and potential for verbal aggression such as cursing and yelling at staff. That care plan called for analyzing triggers, monitoring behaviors, and intervening before agitation escalated. Following the incident, a psychosocial and behavioral care plan was initiated for this resident that described risks for striking out, grabbing others, being combative, verbally aggressive, and using derogatory words, including those related to sexual orientation, toward others. However, review of this resident’s progress notes revealed no documentation of the incident between the two residents, despite the facility’s regional nurse consultant stating that the incident was substantiated as abuse by the facility.
Sanitation, labeling, temperature control, and hand hygiene failures in food service
Penalty
Summary
The facility failed to ensure food was prepared, distributed, and served under sanitary conditions in the main kitchen and three nourishment rooms. During observation, a dishwasher wrapped utensils in napkins with bare hands after touching his face, removing and replacing his hat, and touching other surfaces without washing his hands. A cook prepared sandwiches while wearing gloves but touched the plastic wrap box, bread bag, and utensils without changing gloves, then washed hands for only 10 seconds before putting on new gloves and continuing food preparation. A restorative CNA assisted a resident with eating, stopped to help other residents, picked up a knife from the floor, and then returned to feeding the resident without washing her hands. The lead restorative CNA stated hands should be clean when assisting residents with eating and that hand hygiene should be performed between assisting residents. The facility also failed to ensure time and temperature controlled food was labeled, dated, and stored appropriately. In the main kitchen and nourishment areas, surveyors found multiple undated or unlabeled foods, including containers of juice-like liquids, thawed ground meat, beef, pork, eggs, yogurt-like food, lettuce, seafood salad, sliced tomatoes, turkey sandwiches, fruit containers, soy milk, hummus, and health shakes. Several items were observed at unsafe temperatures, including a refrigerator reading 59 F, health shakes at 68.2 F, sandwiches at 72.5 F, and an opened pudding cup at 58 F. Staff interviews showed some CNAs did not understand pull dates on health shakes, and the DM stated the sandwiches and shakes were taken to the nourishment stations by dietary staff and that cold food should be below 41 F. The dishwashing process was also not maintained at the correct temperatures. The dish machine temperature log had not been filled out since 12/8/25, and while the machine was in use the gauge read 104 F during the cleaning cycle, with the rinse cycle not rising above 104 F. The DM stated the machine was low temperature and should be checked at least twice daily, but the gauge was broken and there was also a problem with the hot water connection in the kitchen. In addition, clean stainless steel pans were observed stacked with visible moisture on the sides and water droplets on the edges, and nourishment refrigerators and freezers in the main kitchen and units contained food debris, spilled liquid, frozen residue, stains, and crumbs. The DM and MTD gave differing accounts of who was responsible for cleaning the nourishment refrigerators, and the MTD stated there was no log of the cleaning schedule.
Failed Shower Room Ventilation
Penalty
Summary
The facility failed to provide adequate outside ventilation in four of four shower rooms. During an environmental tour, surveyors found that the ventilation fan outlets in all four resident shower rooms were without a motor. The [NAME] unit did not have a window or mechanical ventilation. On the Monarch unit, the ventilation outlet was being repaired, but it was without a motor and there was no switch to operate it. The two shower rooms on the Columbine unit also had ventilation outlets with no motor. Surveyors placed a small square of single-ply toilet paper against the vent in all four shower rooms, and the outlets were unable to hold the tissue in place, indicating the fans did not function. The maintenance director confirmed that the exhaust fans in all four shower rooms were without a motor and not functioning, and stated the ventilation outlet had not been working since he became maintenance director. He also stated he did not know why the ventilation outlets were without a motor.
Failure to Maintain Clean, Homelike Environment and Timely Repairs
Penalty
Summary
Surveyors observed that the facility failed to maintain a comfortable and homelike environment for residents across three of four units. Multiple resident rooms were found with broken towel racks, missing towels, and in some cases, only one towel rack for two occupants. A broken window seal in one room allowed ants to enter during rain, and a trash bag was left on the floor outside a bathroom. Additionally, one resident room was noted to be dirty, with a hazy and muted tile floor. In the main shower room, a light fixture was found dangling from the ceiling with exposed wires and cracked drywall, leaving the internal electrical box exposed. Interviews with residents and staff confirmed these deficiencies. A resident reported that the broken window seal allowed ants into the room and that towels were only provided upon request, with no towel rack available for some time. Certified nurse aides stated that all nursing staff were responsible for room cleanliness and towel provision, but towels were only given to residents who asked. The maintenance director was unaware of the extent of broken or missing towel racks and indicated that work orders for repairs were to be initiated by nursing staff. The assistant director of nursing confirmed that every resident's room should have a towel rack and that nursing staff were responsible for providing towels.
Meal Service Delays and Uneven Tray Delivery
Penalty
Summary
The facility failed to treat residents with dignity and respect during meal service in two dining rooms by not providing meals in a timely manner, not notifying residents of delays, not serving tablemates at the same time, and not offering drinks or diversion to residents waiting in the Monarch dining room. The deficiency was based on observations and interviews showing that residents were left waiting for meals, meals were delivered in a random order, and residents had to repeatedly ask staff when they would be served. In the main dining room, observers saw several tables where residents seated together were served at different times. At one table, one resident was served and finished eating before the second resident received a tray. At another table, a resident asked twice when her meal would arrive before being served. At a table with three residents, the trays were delivered at different times over several minutes, leaving some residents waiting while others ate. During another meal service, residents were again served in no apparent order, with one resident waiting until 12:30 p.m. for a meal while a tablemate had already eaten. One resident stated she had waited to eat with her tablemates before and her food became cold. During the evening meal, cold food items were found above serving temperature and were removed from the serving line, delaying service further. Residents in the dining room asked staff what was taking so long, but they were only told the meal would be coming soon and were not given an explanation of the delay. The meal was not announced as delayed to residents or CNAs, and one resident who said he was not feeling well asked for food while waiting. In the Monarch dining room, residents sat waiting past the posted meal time without drinks, snacks, or activity. Residents commented that they were waiting around, wished they had brought cards, and suggested music or entertainment. Staff eventually announced that the kitchen was still working on the meal, drinks were not passed out until later, and when the meal carts arrived, trays were again distributed in a random fashion so tablemates were not served together.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to ensure that four residents reviewed for activities received an ongoing program of activities designed to meet their needs and interests and promote physical, mental, and psychosocial well-being. The report states that personalized and group activity programs were not consistently offered or provided for residents with varying levels of cognitive impairment and physical dependence, despite documented preferences for music, group participation, being around others, going outside, and other individualized leisure interests. One resident with severe cognitive impairment, dementia, and dependence for most care needs was repeatedly observed sitting by the nurses' station or in common areas without meaningful activity. Although the care plan identified interests such as singing, holiday parties, food-and-drink socials, games, arts and crafts, television, movies, and music, the activities director said the resident did not participate because she preferred not to and admitted he had not invited her to group activities. An activities assistant said the resident needed to be invited to each activity and was often sitting by the nurses' station when not participating. Another resident with anoxic brain damage, quadriplegia, and severe cognitive impairment was observed awake in bed or sitting in a wheelchair with no meaningful activity on multiple occasions. The care plan identified interests such as being read to, listening to music, being around animals, watching television, and being around others, but the record showed the last one-to-one activity occurred months earlier. Staff stated the resident had music and television preferences, yet the documentation did not show ongoing one-to-one activity participation as described by staff. A cognitively intact resident with multiple serious medical conditions, including neuropathy, respiratory failure, heart failure, and anxiety, reported that she did not participate in activities and only watched television in her room. She stated staff had stopped assisting her into her wheelchair and that she could not remember the last time she had been assisted to an activity. During observation, she remained in bed while group activities were occurring and was not invited to bingo or other activities she said she would have been interested in attending. A fourth resident with severe cognitive impairment and dementia was observed sitting at the nurses' station while staff walked past without engaging her, and when a tree planting activity occurred, a CNA briefly brought her toward it but then returned her to the nurses' station without asking whether she wanted to participate.
Elevated Resident Beds Left as an Accident Hazard
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for five of 10 residents reviewed on the secured unit because five resident beds were left in an elevated position. Observations showed beds in multiple rooms with the mattress surface approximately four feet high, including beds in rooms [ROOM NUMBER], 408, 410, 401, 309, and 401 A and B and 410 A and B. One resident was observed walking to the bed, reaching up to climb into it, and then sitting on top of the bed with legs dangling about one foot above the floor until a CNA lowered the bed after being notified that it should not be that high. Staff interviews showed the elevated bed positions were intentional. CNAs and an LPN stated beds were kept up so residents would not transfer themselves into bed or use the beds, and because some residents had dementia and were at risk for wandering or falls. One CNA said the resident in one room tried to transfer to the bed often, and another CNA said residents on the secured unit wandered and high beds could create a safety issue. The ADON stated the CNAs had good intentions but acknowledged that elevated beds were an accident hazard.
Incomplete CNA Annual In-Service Training
Penalty
Summary
The facility failed to ensure certified nurse aides received at least 12 hours of annual in-service training, including dementia management training and resident abuse prevention training, to maintain continued competence. Based on interview and record review, three of five CNA training records reviewed did not show completion of the required 12 hours of annual training. The corporate consultant stated that CNA #3, CNA #4, and CNA #5 did not have 12 hours of training. The facility’s In-Service Training policy stated that all staff must participate in initial orientation and annual in-service training, with training completed annually and documented by the staff development coordinator or designee. The staff development coordinator said she was responsible for ensuring all CNAs completed the mandatory 12 hours of in-service training, but she did not have a timeline for checking staff competencies. The three CNAs identified were hired on 10/8/24, 5/22/24, and 11/30/23, respectively.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by each other, resulting in a substantiated incident of resident-to-resident physical aggression. Both residents involved were severely cognitively impaired, with documented histories of behavioral disturbances, including physical aggression and verbal outbursts. On the date of the incident, a certified nurse aide (CNA) witnessed the two residents facing each other and making hand-to-hand, swatting gestures that resulted in physical contact. The CNA immediately intervened by separating the residents and notifying the nurse on duty. Although no injuries were initially reported, a subsequent assessment revealed that one resident had sustained a skin tear on the back of her left hand. Record reviews indicated that both residents had care plans addressing their behavioral issues, including interventions such as providing activities of interest, removing them from high-traffic areas, and ensuring they were kept apart from residents with whom they had previous altercations. Despite these interventions being documented, the incident occurred in a common area, suggesting that the measures in place were not effectively implemented at the time of the altercation. Staff interviews confirmed that both residents were known to exhibit aggressive behaviors and required close monitoring to prevent such incidents. Observations and staff accounts further revealed that both residents were prone to agitation and could be triggered by loud environments or interactions with each other. Staff described using redirection techniques and attempting to keep the residents separated, but the altercation still occurred. The facility's policy required protections against abuse, including resident-to-resident altercations, but the failure to prevent this incident constituted a deficiency in safeguarding residents from abuse.
Failure to Maintain Infection Control Program and Proper Cleaning Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of housekeeping staff not following proper cleaning and hand hygiene procedures. During cleaning of resident rooms, housekeeping staff were observed donning new gloves without performing hand hygiene, handling both clean and dirty items without changing gloves or sanitizing hands, and neglecting to disinfect high-touch surfaces such as call lights, door knobs, and grab bars. Additionally, staff placed contaminated items, such as trash cans, on already cleaned surfaces, leading to potential recontamination. Specific cleaning lapses included not disinfecting reusable cleaning equipment like toilet brushes after use, failing to clean side rails in resident bathrooms, and not sweeping the entire floor prior to mopping. Housekeeping staff also used the same gloves to handle both dirty cleaning rags and resident personal items, such as a juice cup, without changing gloves or performing hand hygiene in between tasks. These actions were inconsistent with both CDC guidelines and the facility's own policies on cleaning, disinfecting, and hand hygiene. Interviews with housekeeping staff and facility leadership confirmed awareness of the correct procedures, but staff admitted to forgetting or skipping steps such as cleaning high-touch areas and performing hand hygiene between glove changes. The infection preventionist and maintenance director both stated that gloves should be changed and hand hygiene performed between tasks, and that high-touch areas must be disinfected daily. Despite this, observed practices did not align with these expectations, resulting in a failure to prevent the development and transmission of infections within the facility.
Failure to Inform Resident of Risks of Refusing Nutritional Supplements
Penalty
Summary
The facility failed to inform a resident of the possible outcome of noncompliance with nutritional supplements. Resident #62, who was cognitively intact with a BIMS score of 15, had diagnoses including hereditary and idiopathic neuropathy, displaced bicondylar fracture of the right tibia, acute kidney failure, chronic respiratory failure with hypoxia, nutritional anemia, heart failure, and anxiety disorder. The resident was dependent on staff for activities of daily living and required significant assistance with transfers, toileting, and personal hygiene. The resident was observed eating very little at lunch, poking at food without taking bites, and appeared malnourished, pale, and dry-mouthed. She stated that she had lost a significant amount of weight since admission and that she did not eat her meals because she did not want to be obese. She also said she often skipped dinner or ate only applesauce and reported that staff had not discussed the risks of significant weight loss with her. Record review showed the resident was at nutritional risk due to varied oral intake, a history of significant weight loss, diuretic use, and heart failure. The physician documented that the resident had lost close to 40 pounds and was very unmotivated to eat, and the interdisciplinary team discontinued some supplements because of refusals. The resident continued to refuse most nutritional supplements and did not consume enough of her meals, and the record did not show documentation that she had been educated about the risks or health effects of her continued noncompliance with the nutritional supplements.
Failure to Follow Up on Cataract Surgery and Vision Services
Penalty
Summary
The facility failed to ensure one resident received proper follow-up for vision services and assistance with arranging cataract surgery. Resident #93 had diagnoses including dry eye syndrome, dementia, and depressive episodes, and the MDS showed moderate cognitive impairment with a BIMS score of 13 out of 15. The resident reported that she could not see out of her left eye, had been told after an eye appointment that cataract surgery was needed, and said the facility had not followed up to arrange the surgery. She also stated she could not obtain new glasses until the cataract was repaired and that her vision problems made it hard to read and contributed to feeling depressed. Record review showed the resident’s care plan identified eyeglasses for vision support and included monitoring for changes in vision and eye symptoms. A social services note documented that the resident requested help scheduling cataract surgery and that the request was forwarded for transportation and follow-up. A physician note documented eye drops for the left eye cataract, and a nursing note documented that after a medical appointment the eye physician said the resident was approved for surgery and would contact the primary physician to coordinate it. However, the electronic medical record did not show any additional documentation that the facility attempted to schedule the cataract surgery after that appointment. Staff interviews showed confusion and lack of follow-through in coordinating the surgery. The SSA said the resident had a cataract evaluation, was referred for a B Scan, and that the referral was resent when needed. The scheduler said she assumed the eye care center would contact her after testing was completed and did not follow up when that did not happen, later acknowledging she was responsible for ensuring appointments were scheduled and that she should have called sooner. The SSD stated the facility should have followed up with the eye care center after about a week when no surgical appointment had been arranged, and the ADON said the scheduler should have followed up within two weeks of testing when no contact had been received.
Deficient Call Light System Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly throughout the building, resulting in staff being unable to hear or see call light alerts when away from the centralized nurse's station. Observations revealed that the audible alarm for the call light system was only present at the nurse's station and was not audible down the hallways. The visual indicators for activated call lights were also obstructed by the building's layout, making it difficult for staff to identify which rooms required assistance and in what order. The call light system did not provide information on how long a call had been active or which resident had called first. Multiple residents reported significant delays in staff response to call lights, with some waiting up to two hours for assistance with pain management, toileting, or urgent medical needs. One resident described an incident where her roommate experienced difficulty breathing and had already activated the call light, but staff did not respond until additional efforts were made to attract attention. Another resident recounted waiting over an hour for help after an incontinence episode, and a respiratory therapist documented an instance where a resident in need of immediate medical attention was not attended to because the call light alarm was not heard. Internal audits and grievance records confirmed a pattern of delayed call light responses, with documented response times ranging from one minute to over an hour and multiple grievances filed regarding long waits for care. Staff interviews corroborated these findings, with CNAs and LPNs stating that the call light alarms were difficult to hear or see from various locations in the facility, and that the system did not indicate which resident had been waiting the longest. The facility's policy required call lights to be accessible and to relay alerts directly to staff or a centralized location, but the current system did not meet these requirements due to technological and structural limitations.
Failure to Administer Medications Timely and as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received medications in a timely manner as prescribed, in accordance with professional standards of practice and the resident's comprehensive care plan. The resident, who was over 65 years old and had multiple diagnoses including COPD, respiratory failure, atrial flutter, heart failure, and atrioventricular block, was cognitively intact but dependent on staff for most activities of daily living. The resident reported concerns about not receiving morning medications at the scheduled time, sometimes receiving them as late as noon, and was not informed of any changes to medication times. A review of the medication administration audit revealed that over a two-week period, the resident received a significant number of late medication doses. Specifically, 102 medications were administered late, with the majority given by one LPN. Medications such as Baclofen, Eliquis, and Gabapentin were repeatedly administered outside the prescribed time windows, sometimes several hours late. On multiple occasions, all scheduled morning medications were given more than an hour past the administration window, and in some cases, doses were given in close succession rather than at evenly spaced intervals as recommended by professional guidelines. This inconsistent timing did not support optimal therapeutic effects or consistent management of the resident's conditions. Staff interviews indicated that medication administration was delayed due to high resident acuity, staff needing to assist with care tasks, and challenges in managing the medication cart assignments. The facility had recently changed the medication administration schedule to a three-hour window to accommodate resident preferences and staff workflow, but staff were still expected to administer medications within this window. The DON was unaware of the extent of late medication administration until an audit was conducted at the request of surveyors. Additionally, there were concerns that some medications may have been administered on time but documented later, which is not consistent with professional nursing practice.
Failure to Provide Adequate Psychosocial Support for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with mental disorders and psychosocial adjustment difficulties. The resident, a 69-year-old male, was admitted with diagnoses including anxiety, head injury, dementia, depression, and epilepsy. Despite having a care plan that included non-pharmacological interventions and behavioral and psychological services, the facility did not adequately monitor or assess the resident's emotional and psychosocial needs. The resident displayed behaviors such as delusions, paranoia, and aggression, which were not effectively managed or documented by the staff. The facility's records revealed multiple instances where the resident exhibited distress and aggressive behaviors, including pacing, hallucinations, and attempts to leave the facility. Staff interventions were limited to redirection and reassurance, and there was a lack of follow-up from the social services director regarding the resident's repeated behaviors. Additionally, the facility did not document any psychological or psychiatric evaluations or behavior health provider notes, and the resident was not reviewed in the psychoactive drug meetings despite being on psychoactive medications. Interviews with staff indicated that the resident's behaviors were known, but the interventions were not personalized or effectively communicated to the floor staff. The social services department failed to send referrals for behavioral health counseling, and the resident was not evaluated by a psychiatrist. The facility began seeking alternative placement for the resident due to his aggressive behaviors, but without providing the necessary psychiatric or psychological support, it could not be confirmed that the facility was unable to meet the resident's needs.
Failure to Reconcile and Destroy Controlled Substances
Penalty
Summary
The facility failed to maintain a system of records and disposition for controlled drugs, leading to an inability to accurately reconcile these substances. The facility's policy, revised in November 2022, mandates compliance with laws and regulations regarding the handling, storage, disposal, and documentation of controlled medications. However, during an observation on September 5, 2024, it was found that the inventory of discharged or discontinued controlled substances awaiting destruction was stored in a locked file cabinet in the Director of Nursing's (DON) office. The medications dated from March 2024 to September 2024, indicating a lack of timely reconciliation and destruction. Interviews with the DON and the Nursing Home Administrator (NHA) revealed that there was no system in place to document the tracking of medications after they were discontinued and taken into custody for destruction. The DON admitted to not having destroyed any items since taking her position in February 2024 and acknowledged the absence of a reconciliation system for discontinued medications. The NHA was unaware of the large inventory awaiting destruction and noted that the facility's pharmacist had not completed reconciliation monitoring of controlled substance destruction.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #11, who was unable to perform activities of daily living independently. The resident, who was cognitively intact and required assistance with toileting hygiene, was observed sitting in his own feces for an extended period. During an observation period, the resident waited two hours and 45 minutes for assistance after activating the call light, which was turned off by a CNA who did not return to provide care. Resident #11, who had diagnoses including type 2 diabetes with diabetic neuropathy and benign prostatic hyperplasia, expressed frustration over the long wait times for incontinence care, stating it was a frequent issue, especially on weekends. The resident's care plan did not include specific interventions for bowel incontinence, despite being incontinent of both bowel and bladder. Interviews with staff revealed inconsistencies in the frequency of incontinence checks, with some staff indicating checks should occur every two hours, while others noted variability based on the resident's needs. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain personal hygiene. However, interviews with staff, including CNAs and the DON, highlighted a lack of adherence to this policy, with reports of residents being left without care for extended periods. The DON acknowledged that care plans generally did not specify timeframes for incontinence checks, contributing to the deficiency in providing timely care for Resident #11.
Deficiencies in Treatment and Medication Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for three residents. For Resident #2, the facility did not follow physician's orders for skin and wound care. The resident, who was at risk for skin breakdown due to multiple health conditions, had specific orders for cleansing and applying barrier cream to the peri-area and elevating and offloading the right heel. These treatments were not administered as ordered on several occasions, as documented in the medication administration record (MAR). Resident #12 also did not receive wound care as ordered by the physician. The resident had a history of skin issues and was at risk for pressure ulcer development. Despite having specific orders for surgical site care, the treatments were not administered as documented in the MAR. Interviews with staff revealed a lack of awareness of the physician's orders and issues with documentation, contributing to the failure in providing the necessary care. Resident #7 experienced issues with medication administration, specifically with methadone for pain management. The resident reported that the pharmacy did not keep the medication in stock, leading to missed doses and inadequate pain control. The MAR indicated missed doses, but there were no corresponding nursing notes explaining the reasons for these omissions. Staff interviews highlighted a lack of a systematic approach to medication ordering and documentation, which contributed to the deficiency in medication administration.
Inconsistent EBP Implementation in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with a chronic wound. The Centers for Disease Control and Prevention (CDC) guidelines and the facility's own policy require the use of personal protective equipment (PPE), including gowns and gloves, during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms (MDROs). However, observations revealed that a certified nursing aide (CNA) did not perform hand hygiene or don the necessary PPE before entering the room of a resident on EBP to perform incontinence care. The deficiency was further highlighted through staff interviews, which indicated a lack of understanding and adherence to EBP protocols. The CNA involved admitted to not seeing the EBP sign and was unsure of its implications, leading to her failure to wear the required PPE. Other staff members, including licensed practical nurses (LPNs) and registered nurses (RNs), provided varying interpretations of when PPE should be used, indicating inconsistency in the application of EBP guidelines. This inconsistency was evident as some staff did not wear PPE during interactions that required it, such as checking or changing briefs for residents with wounds or indwelling devices. The infection preventionist (IP) acknowledged the issue, noting that she conducted rounds and audits to monitor compliance with EBP but had observed failures in adherence. Despite initial training and ongoing spot-training efforts, the staff's inconsistent application of EBP protocols contributed to the facility's failure to maintain a safe and sanitary environment, as required by infection control standards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 80 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Falcon Heights Rehabilitation And Nursing Llc | 1.8 mi | ★★★★★ | 2 | 0 |
| Fountain View Rehabilitation And Nursing Llc | 2.3 mi | ★★★★★ | 2 | 0 |
| Medallion Post Acute Rehabilitation | 2.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Colorado Springs | 2.9 mi | ★★★★★ | 5 | 1 |
| Advanced Health Care Of Colorado Springs | 3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mountain View Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.