The November 17 incident at Mountain View Health & Rehabilitation involved a severely cognitively impaired male resident who had been receiving treatment for a chronic pressure ulcer on his right buttock since his January admission. Federal inspectors found that staff violated basic wound care protocols by leaving the patient vulnerable to infection.
CNA K noticed the dressing was missing earlier in her shift but never told nursing staff. When she and LVN J turned the resident at 11:46 AM, inspectors observed a thick white substance covering the patient's buttocks and the open wound itself. No protective dressing covered the injury.
"She did not report the absence of the wound dressing," inspectors wrote about CNA J's response when questioned. Both assistants confirmed they had been trained to immediately report missing dressings on any resident with pressure ulcers.
The resident's medical records revealed the severity of his condition. His quarterly assessment showed he scored just 2 points on cognitive testing, indicating severe impairment. He required a pressure-reducing device for his bed, specialized wound care, and regular application of medications and dressings.
His care plan specifically called for staff to monitor the effectiveness of treatments by "replacing loose or missing dressings." The facility's own policy required staff to "report abnormalities to nursing staff to prevent skin breakdown, promote healing, and prevent infection."
The Director of Nursing acknowledged the dangerous lapse during her interview with inspectors at 12:28 PM. "Wounds without dressings increased infection risk and delayed healing," she told investigators. She called it "unacceptable for the resident not to have a dressing on his pressure ulcer as ordered in his care plan."
Pressure ulcers develop when prolonged pressure, friction, or moisture reduces blood flow to tissue, causing damage that can extend deep into muscle and bone. The resident's injury had persisted since before June, when his medical history documented the chronic condition alongside iron deficiency and anemia.
The Director of Nursing explained that checking dressings was the wound care nurse's responsibility, but emphasized that any licensed practical nurse or certified nursing assistant who noticed a missing dressing had to report it immediately.
Neither CNA followed that protocol.
The facility's written policy promised comprehensive wound management: maintaining skin integrity, implementing turning schedules, maintaining hygiene, and conducting routine skin assessments. Staff were specifically directed to report any abnormalities to prevent skin breakdown and infection.
Federal investigators determined the violation placed residents receiving wound care at risk for inadequate treatment that could worsen their injuries. The inspection classified the harm level as minimal, but noted the potential for actual harm to vulnerable patients.
The resident had been living at Mountain View Health since January 5, nearly eleven months before inspectors discovered the exposed wound. His medical records showed ongoing treatment for the pressure ulcer throughout his stay, with regular applications of medications and specialized dressings designed to promote healing.
Mountain View Health operates at 1600 Muchison Road in El Paso. The facility is required to submit a plan of correction to address the wound care deficiencies identified during the November complaint investigation.
The thick white substance inspectors observed covering the resident's wound and surrounding skin suggested possible infection or drainage that the missing dressing should have contained and protected. Without proper coverage, such wounds remain exposed to bacteria and contaminants that can cause serious complications.
The resident's severe cognitive impairment meant he likely could not advocate for himself or alert staff to problems with his care. His BIMS score of 2 indicated he required extensive assistance with decision-making and communication about his medical needs.
Federal regulations require nursing homes to provide wound care consistent with professional standards to promote healing and prevent new injuries. The Mountain View case demonstrates how basic protocol failures can compromise care for the facility's most vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain View Health & Rehabilitation from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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