The resident filed a grievance on November 8, 2024. The nurse continued working with that resident for weeks afterward.
Mountain View Post Acute failed to properly investigate multiple allegations of abuse and neglect, federal inspectors found during a January 2025 inspection. In four separate cases, staff accused of verbal abuse, rough handling, and discriminatory comments either weren't investigated at all or continued working with residents during investigations that should have removed them from patient care.
The facility's own policy required immediate removal of staff involved in abuse allegations "until a thorough investigation can be completed." That didn't happen.
The Cigarette Incident
Resident 41, who was cognitively intact and able to communicate clearly, described the November encounter with Staff F to inspectors. The nurse had come into their room early in the morning, yelling and grabbing their hand to shake them awake. When the resident hesitated to hand over their smoking supplies, the nurse "kept yelling/demanding and then threatened to search the resident's room."
The resident gave up their cigarettes and lighter. Later that day, when they asked the nurse not to speak to them rudely, "the nurse started to yell at Resident 41 again."
The grievance sat unaddressed for 26 days before anyone interviewed the resident. Progress notes from November 28, December 18, and December 20 show Staff F continued working with Resident 41 after the allegations were made.
Staff E, the Social Service Director, told inspectors the incident "was an allegation of verbal abuse from Resident 41 against Staff F and that it should have been reported/investigated." Staff E acknowledged they "did not take Staff F off shift in order to protect Resident 41."
The Director of Nursing Services initially didn't recognize the grievance as an abuse allegation. After re-reading it during the inspection, she agreed "it was an allegation of verbal abuse" and "Staff F should have been removed from working with residents until a thorough investigation was completed."
Rough Handling Goes Unreported
Resident 28 reported that a registered nurse and nursing assistant were "extremely rough" during care, with the nurse shoving their left hip while rolling them to their side. The resident yelled for the nurse to stop multiple times. Due to continued pain, they needed diagnostic imaging to ensure no injuries occurred.
No incident was ever logged. No grievance was filed. The nursing assistant who witnessed the event confirmed the account to inspectors, saying the nurse was "in a hurry" and "grabbed Resident 28's left leg the wrong way and it hurt the resident."
Forced Care and Discrimination
In September 2024, a nursing assistant entered Resident 42's room and insisted on providing incontinence care despite the resident's refusal. The assistant "tried to make [Resident 42] anyway," according to a grievance form.
The form indicated the nursing assistant would be "removed from the facility staffing list and not allowed to work in the facility." Instead, staffing records show the assistant worked 17 additional shifts through November 28, 2024.
In another case, a nursing assistant called Resident 27 "gay" for wearing black nail polish, hurting the resident's feelings. The August 2024 grievance was handled as a personality conflict rather than potential discrimination. The assistant remained unidentified, and no formal investigation occurred.
System Failures
The pattern revealed a facility struggling with basic abuse prevention protocols. The Assistant Director of Nursing Services told inspectors she was "not aware of Resident 28's incident regarding rough handling nor Resident 42's incident regarding refusal of care." She said she would have "removed Staff Y and Staff CC from direct patient care and started investigations to rule out abuse or neglect, had they known."
Staff interviews revealed confusion about reporting requirements and investigation procedures. Some incidents weren't recognized as potential abuse. Others were treated as routine grievances rather than serious allegations requiring immediate action.
Additional Care Failures
The inspection uncovered broader care deficiencies affecting dozens of residents. Staff shortages led to residents going without showers for weeks. Resident 37 told inspectors they hadn't showered in nearly two weeks and described their "rear end" as "so hot" they feared leaving "burn marks on the wall."
Resident 22 hadn't received a shower in over three weeks, with oily hair and long, dirty fingernails. "I wish someone had time to do it," they told inspectors.
The facility's restorative nursing program had collapsed. Resident 13, who wanted to resume physical therapy after recovering from pneumonia, said the restorative assistant "come in once and a while about once or twice a week and ask me to raise my left arm." Resident 42, who used to walk before hip surgery, could no longer lift their right leg off the bed and hadn't received prescribed exercises "in a while."
Staffing Crisis
Staff interviews painted a picture of chronic understaffing. Agency workers received 30-minute orientations instead of the typical one-to-two days. Nursing assistants assigned to showers or restorative care were regularly pulled to cover other duties, leaving specialized programs unfulfilled.
One registered nurse described their hallway as "the worst of the worst" they'd ever worked, saying they had "time to pass the residents their medications but if they required anything else, there would be no way to get it done."
A resident with serious mental health issues and substance use disorder made suicidal statements and threw objects in their room, but staff were too busy to contact the medical provider for additional interventions. The provider told inspectors they hadn't been informed of the resident's deteriorating condition "until just a few minutes ago."
Regulatory Response
The inspection identified violations in abuse prevention, resident rights, care planning, and staffing adequacy. The facility's own assessment hadn't been updated in 16 months and contained outdated information about programs and staffing levels.
For residents like the one who was grabbed and yelled at for their cigarettes, the failures meant weeks of continued exposure to staff who had allegedly mistreated them. The facility's administrator acknowledged "the correct process was not followed" and that residents should have been protected through proper investigations and staff removal.
The inspection report provides no timeline for when these systemic problems might be resolved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain View Post Acute from 2025-01-14 including all violations, facility responses, and corrective action plans.
