Mountain View Health & Rehabilitation

F 0656

explained to the resident what they were doing, ensuring the resident understood. No distress noted on Resident #3. Call light was placed within reach.

Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain View Health & Rehabilitation

1600 Muchison Rd El Paso, TX 79902

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interviews, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infections for 1 of 2 (Resident #2) residents reviewed for quality of care.The facility failed on 11/17/2025 to ensure the pressure ulcer on Resident #2's right glute was covered with a dressing as ordered.This deficient practice could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds. The findings included: Record review of Resident #2's face sheet dated 11/17/25 revealed a [AGE] year-old male with an admission date of 1/5/25.Record review of Resident #2's History and Physical dated 6/19/25 revealed the resident had a diagnosis of chronic right gluteal pressure ulcer (an injury to the skin and underlying tissue over the buttocks (gluteal area) caused by prolonged pressure, friction, shear, or moisture that reduces blood flow to the area, leading to tissue damage), iron deficiency and anemia. Record review of Resident #2's quarterly MDS assessment dated [DATE REDACTED] revealed he had a BIMS score of 2 indicating the resident was severely cognitively impaired. Under section M Skin Conditions, the MDS revealed the resident needed

a Pressure Reducing device for bed, requiring pressure ulcer/injury care, application of nonsurgical dressings, Applications of ointments/medications.Record review of Resident #2's care plan dated 09/02/2025 revealed Resident #2 had a pressure ulcer or a potential for pressure ulcer development. The care plan revealed the resident needed to have intact skin, free of redness, blister or discoloration and asked for staff interventions which included administration of medications as needed, administering treatments as ordered and monitoring effectiveness by replacing loose or missing dressings.In an

observation on 11/17/25 at 11:46 AM, LVN J and CNA K turned Resident #2. CNA K removed the brief, and

a thick white substance was observed on the resident's buttocks and directly on the pressure injury. The wound had no dressing in place. In an interview 11/17/25 at 11:52 AM, CNA J stated she did not report the absence of the wound dressing. She stated staff were trained to immediately report missing dressings. In

an interview on 11/17/25 at 11:54 AM, CNA K confirmed she noticed the dressing was missing earlier in

the shift and did not notify nursing staff. She stated staff were trained to report missing dressings for any resident with pressure ulcers.In an interview on 11/17/25 at 12:28 PM, the DON stated wounds without dressings increased infection risk and delayed healing. The DON stated it was unacceptable for the resident not to have a dressing on his pressure ulcer as ordered in his care plan. The DON stated checking that dressings were in place as ordered was the responsibility of the wound care nurse. The DON stated that if any LVN or CNA noticed the wound had no dressing, it had to be reported immediately to the wound care nurse.Record review of the facility's policy titled Pressure Injury: Prevention, Assessment and Treatment read in part: Staff will maintain skin integrity, implement turning schedules, maintain hygiene, assess skin routinely and report abnormalities to nursing staff to prevent skin breakdown, promote healing, and prevent infection.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain View Health & Rehabilitation

1600 Muchison Rd El Paso, TX 79902

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

repositioning assistance, dated 11/11/25 signed by all staff.Proficiency Assessment for Incontinence Care and repositioning dated 11/11/25, was signed by all staff. Interviews on 11/13/25: RN G on 11/13/25 at 11:54 AM, CNA E on 11/13/25 at 11:40 AM, CNA F on 11/13/25 at 11:42 AM, CNA H on 11/13/25 at 12:01 PM and CNA I on 11/13/25 at 12:03 PM, LVN B on 11/13/25 at 1:21 PM, reflected they had received in-service on following the resident's care plans and on two-person repositioning; on 11/11/25, these staff members all verbalized they needed to ask for assistance from another staff member and review and follow

the Kardex or care plan in PCC (Point Click Care, the facility's electronic health record software) for the residents at the facility. In an interview on 11/13/25 at 11:53 AM, CNA E stated all staff had been in-serviced on 11/11/25 on repositioning and how to look for information in the Kardex[KS1] (a quick-reference summary sheet that gives staff a snapshot of a resident's key care information. It's used to help nurses and CNAs quickly understand what a resident needs without having to dig through the full medical chart) in the residents' care plans. CNA E said if a resident required two staff members for repositioning, they always needed to request help from a coworker. CNA E said the potential outcome for not following a resident's care plan could result in the residents not receiving the proper treatment or care

they needed. In an interview on 11/13/25 at 11:55 AM, CNA F reported all staff had received in-service on 11/11/25 regarding residents' care plans, where to find them in the system and how to read them. CNA F stated all staff from the facility were expected to always follow the residents' care plans. CNA F explained not following a resident's care plan could result in neglecting their needs or even physical injury if staff did not familiarize themselves with the residents' care plans.In an interview on 11/13/25 at 12:01 PM, CNA H said staff have been trained on 11/11/25 on how to find the residents' care plans and Kardex in the facility's system. CNA H stated it was important for all staff to be familiarized with the residents' care plans to ensure

they were providing the care the residents needed and to avoid any potential hazards or injuries to residents by not properly following the care plans developed for each resident.In an interview on 11/13/25 at 12:05 PM, CNA I explained the staff were taught how to check for care pans and the residents' charts and Kardex. CNA I stated when a resident was listed as needing two staff for repositioning, the information would be documented in the resident's care plans. CNA I said not following the care plans developed for each resident was not acceptable because it could lead to neglecting the residents with the care they needed which could result in injuries to both residents and staff in the facility.Observations: In an

observation on 11/13/25 at 11:40 AM, CNAs E and F demonstrated repositioning procedures with Resident #2. Both CNAs followed repositioning procedures successfully and explained to the resident what they were doing, ensuring the resident understood. CNAs placed call light within reach. No distress noted on Resident #2. In an observation on 11/13/25 at 12:00 PM, CNAs H and I demonstrated repositioning procedures with Resident #3. Both CNAs followed repositioning procedures successfully and explained to the resident what

they were doing, ensuring the resident understood. No distress noted on Resident #3. Call light was placed within reach.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain View Health & Rehabilitation

1600 Muchison Rd El Paso, TX 79902

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

residents that have wounds . She said the staff should use a gown and gloves when having direct contact with the residents to prevent cross contamination and spread of infection. The DON stated she was unsure when staff were last trained on EBP.In an interview on 11/17/25 at 1:35 PM, the Doctor stated if the facility had posted an EBP sign by a resident's door, the staff had to follow the facility's recommendations and that

the probable negative outcome would be spreading of infection and cross contamination to other residents

in the facility if staff were not wearing their PPE. In an interview on 11/17/25 at 2:13 PM, the Administrator stated if there was a sign posted by the door of a resident stating that there were enhanced barrier precautions, the expectation was for the staff to follow that procedure and for them to wear those barriers.

The Administrator said by staff not following these protocols there was a risk of spreading infection to other residents in the facility when staff went into different rooms. The Administrator stated there was a potential to spread infections throughout the facility by not wearing PPE.Record review of the facility's policy updated

on 03/2024 and titled Infection Control Plan: Overview, read in part Infection ControlThe facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.Preventing Spread of InfectionWhen the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility will isolate the resident.The facility will prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.The facility will require staff to Donn and Doff PPE before and after contact with resident who needs isolation to prevent the spread of infection to others in the facility.

Event ID:

Facility ID:

If continuation sheet