Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain View Health And Rehabilitation during CMS and state inspections, most recent first.
Staff failed to provide adequate supervision and follow elopement procedures when an unsecured window was discovered on a secured memory care unit. A resident with schizophrenia and documented elopement risk, whose care plan included safety on a secured unit and monitoring for exit-seeking, was last seen near the nurses’ station early in the morning. When a restorative aide reported that plywood covering a previously broken window was missing, an LPN assumed another exit-seeking resident had removed it and did not conduct a head count, despite facility guidance requiring an immediate count when an open door or window was found. The resident was later found to be missing during breakfast, leading to a delayed recognition of the elopement and delayed activation of the facility’s elopement response.
A resident on anticoagulation therapy experienced a fall with head injury and was not promptly reported to the on-call provider by the night shift RN. The resident was later found to have significant bruising and cognitive changes, prompting the day shift LPN to contact the NP, who arranged for hospital evaluation. Facility documentation and interviews confirmed delayed provider notification and lack of a clear policy for such events.
A newly hired CNA began work without documented completion of required elder abuse prevention training, contrary to facility policy mandating such training during initial orientation and before floor assignment. The Administrator confirmed the lapse in timely training for this staff member.
A resident with dementia and a known history of wandering, who was care planned for a secured unit, was able to leave the facility unsupervised and was later found re-entering through the main entrance. Facility policy required staff accompaniment for such residents outside the secured area, but the resident was unaccounted for by staff for over 30 minutes, indicating a lapse in supervision and safety measures.
The facility failed to protect residents from physical abuse, resulting in harm to two residents. One resident with severe cognitive impairment was repeatedly involved in altercations, sustaining lacerations requiring staples. Another resident sustained a facial fracture after being attacked by a resident with a history of aggressive behavior and medication refusal. The facility's inadequate management of these behaviors and delayed interventions contributed to these incidents.
The facility failed to secure a medication cart, properly label a multi-dose vial, and remove outdated medications. An unlocked medication cart was found unattended with a resident nearby, and a multi-dose vial lacked the required date and initials. Outdated medications were discovered on several carts and in a storage room, contrary to facility policies.
A LTC facility reported a medication error rate of 53.85%, with errors including late administration and incorrect dosages. An LPN administered medications beyond the allowed time window, and a resident self-administered medication without proper authorization. The facility lacked a clear policy on medication errors.
A resident's right to self-determination was violated when a CNA, unaware of the resident's preference not to be disturbed at night, attempted to turn the resident, resulting in bruising. The resident, with conditions like arthritis and COPD, had a care plan indicating they should not be awakened for rounds. The facility's policy on resident rights was not upheld, leading to an investigation.
A resident with anxiety and insomnia was disturbed by loud staff during the night shift, despite being moved away from the nurses' station. Multiple grievances about noise were documented, but the facility had not conducted a root cause analysis to address the issue effectively.
A facility failed to ensure the accuracy of an MDS assessment for a resident with low back pain, leading to potential issues in their care plan. The MDS assessment inaccurately documented multiple falls, while progress notes only recorded one fall. The MDS Coordinator confirmed the assessment's inaccuracy.
A resident with spinal stenosis and chronic pain syndrome did not receive showers as per their preference and care plan in an LTC facility. Despite the care plan documenting showers twice a week, the resident only received them once a week due to time constraints and prioritization of other residents. The DNS acknowledged the lack of adherence to the facility's standard practice for showering.
The facility failed to conduct weekly evaluations of a resident's surgical wounds, report significant cognitive decline and infection signs to a physician, and adhere to blood sugar monitoring orders for residents with diabetes. These deficiencies involved a resident with chronic surgical wounds, another with a significant drop in mental status, and a third with diabetes whose blood sugar levels were not consistently checked as ordered.
A resident with chronic respiratory conditions was receiving oxygen at an incorrect flow rate of three LPM instead of the physician-ordered two LPM. This discrepancy was observed during a survey, and both an LPN and the DNS confirmed the error, which did not align with the facility's policy requiring adherence to physician orders for oxygen administration.
A facility failed to identify triggers for a resident with PTSD, risking re-traumatization. The resident's care plan lacked specific triggers and tailored interventions, and the LPN could not specify where baseline behaviors were documented. The DNS admitted to not knowing the resident's PTSD triggers, despite the facility's policy on trauma-informed care.
The facility failed to protect resident-identifiable information and maintain accurate medical records. Unattended computer screens on medication carts displayed resident information, confirmed by an LPN and RN. Additionally, a resident's medical record inaccurately documented no signs of infection for an elbow abrasion, despite evidence of cellulitis and antibiotic treatment. The DNS confirmed the presence of a wound, and facility policy required accurate documentation.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage three pressure ulcer, as required by a physician's order. Observations showed missing EBP signage, and staff interviews revealed confusion about EBP protocols. The CNA and LPN did not follow EBP guidelines, and the Director of Nursing Services and Infection Preventionist confirmed the oversight.
A resident with chronic conditions did not receive an influenza vaccine despite guardian consent, due to an oversight by the facility. The resident's clinical record lacked documentation of vaccine administration, which was confirmed by the Infection Preventionist.
The facility failed to prevent resident-to-resident abuse for seven residents and employee-to-resident neglect for one resident. Incidents included physical altercations between residents and a delayed medical response to a resident's fall, highlighting lapses in care and reporting procedures.
A resident with a history of traumatic brain injury and epilepsy was found on the floor with the mattress from the bed. Despite a care plan requiring fall mats, these were not in place, leading to the resident being sent to the hospital where leg fractures were discovered. Staff mistakenly placed the fall mats by the resident's roommate's bed.
A resident with multiple diagnoses, including dementia and repeated falls, experienced a delay in medical attention after a fall because a Hospitality Aide and CNA did not report the incident to a Licensed Nurse. The resident was later found to have a fractured left hip and required hospitalization.
Failure to Verify Resident Presence After Discovery of Unsecured Window on Secured Unit
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention on a secured memory care unit when staff did not verify that all residents were present after discovering an unsecured window. A resident with paranoid schizophrenia and unspecified psychosis, identified through multiple elopement risk evaluations as an elopement risk due to schizophrenia and wandering behaviors, had care plan interventions that included ensuring safety on a secured unit and monitoring exit-seeking behaviors such as pushing on exit doors. On the morning of the incident, a restorative nurse aide notified an LPN that the plywood covering a previously broken window on the secured unit was missing. The LPN, who had last seen the resident near the nurses’ station at approximately 6:00 AM, assumed the plywood had been removed by another resident known for breaking windows and exit-seeking, and did not initiate a head count or otherwise confirm that all residents on the unit were present. Later that morning during breakfast, staff noticed the resident was not present in the dining room and began searching for the resident on the unit and then in the surrounding area after the resident could not be located. The administrator confirmed that when staff discovered the missing plywood and unsecured window between 7:00 AM and 8:00 AM, they notified the administrator and confirmed only that the resident assigned to that room was present, but did not complete a full resident count on the secured unit. The facility’s elopement policy defined elopement as a resident exiting the facility or entering an unsafe area without staff knowledge and required care plan interventions based on elopement risk evaluations. An additional facility document on elopement risk directed staff to ensure all doors and windows in the memory care unit were locked and secured and to complete an immediate head count for the entire facility if any potential elopement risk, such as an open door or window, was identified. Staff’s failure to follow these procedures resulted in delayed identification of the resident’s elopement and delayed implementation of the facility’s elopement response procedures.
Failure to Notify Provider After Resident Fall with Injury
Penalty
Summary
The facility failed to notify the on-call medical provider after a resident experienced a fall with injury, resulting in bruising to the forehead. The resident, who had a history of traumatic subdural hemorrhage, atrial fibrillation, congestive heart failure, and was on anticoagulation therapy, was found on the floor with purple lumps on the forehead and a small skin tear on the left wrist. The RN on duty performed an assessment, provided basic wound care, and notified the Executive Director, Resident Care Manager, Nurse Practitioner (NP), and Guardian, but did not contact the on-call medical provider at the time of the incident. The resident was monitored, and pain medication was administered. Later, during the day shift, an LPN noticed additional bruising and changes in the resident's cognition and reached out to the NP, who then assessed the resident and decided to send the resident to the emergency department for further evaluation due to the high risk associated with anticoagulation. Review of facility documentation and interviews confirmed that the NP was not notified of the fall and injury until the day shift, several hours after the incident. The facility lacked a clear policy for physician notification related to change of condition, and the relevant fall management policy did not specify provider notification requirements.
Failure to Complete Timely Elder Abuse Prevention Training for New CNA
Penalty
Summary
The facility failed to ensure that initial elder abuse prevention training was completed in a timely manner for one newly hired Certified Nursing Assistant. Personnel records showed that this staff member, hired on 11/01/2025, did not have documented evidence of completing elder abuse prevention training upon hire. According to the facility's policy, all staff, including contract staff and volunteers, are required to receive training on abuse prevention, reporting, and intervention upon hire, annually, and as needed. The Administrator confirmed that abuse training should be completed during the first orientation and that staff are not permitted to work on the floor prior to completing this training. However, the record review and Administrator interview confirmed that this requirement was not met for the identified employee.
Failure to Prevent Elopement of Resident with Dementia
Penalty
Summary
A resident with a history of dementia, memory deficit, and wandering behaviors was identified as being at significant risk for elopement, as documented in their Elopement Risk Evaluation and care plan. The care plan specified that the resident required a secured unit due to impaired safety awareness and a tendency to wander. Despite these documented risks and interventions, the resident was able to leave the secured unit and exit the facility without staff knowledge. The incident was discovered when the resident was observed re-entering the facility through the main entrance from outside, after being unaccounted for by staff for approximately 35 minutes. The facility's policy required that residents at risk for elopement residing in a locked unit be accompanied by staff when outside the facility. The Executive Director confirmed the elopement and was unable to determine how the resident exited the secured area, indicating a failure to provide adequate supervision and maintain a hazard-free environment as required by facility policy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in harm to two residents. Resident #72, who had severe cognitive impairment and was at risk for altercations due to dementia, was involved in multiple incidents of resident-to-resident abuse. On one occasion, Resident #72 was hit by another resident, resulting in lacerations requiring staples. The facility's care plan for Resident #72 included interventions to redirect the resident away from others, but these measures were insufficient to prevent the incidents. Resident #240, who had a history of aggressive behavior and refused medications, was involved in several altercations with other residents, including hitting Resident #72. Despite being identified as having potential for physical aggression, the facility did not effectively manage Resident #240's behavior, leading to repeated incidents of abuse. The facility's system for reviewing behavioral documentation was inadequate, delaying necessary interventions such as 1:1 supervision. Another incident involved Resident #104, who sustained a facial fracture after being attacked by Resident #140. Both residents had cognitive impairments and behavioral disturbances. Resident #140 had a history of refusing medications and exhibiting aggressive behavior. The altercation was initially unwitnessed, but staff intervened upon hearing the commotion. The facility's failure to manage Resident #140's behavior and ensure the safety of Resident #104 resulted in significant physical harm and subsequent regressive behaviors in Resident #104.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications, as evidenced by several observations and interviews. An unattended medication cart was found unlocked in the 100 hall, with a resident standing next to it, posing a risk of unauthorized access to medications. The Director of Nursing Services (DNS) confirmed that medication carts should be secure when not in use, and the facility policy mandates that only licensed nurses and authorized personnel should have access to medication carts, which should remain locked when unattended. Additionally, a multi-dose vial of Tubersol was found in a medication storage room without the date opened or the initials of the first person to use it, contrary to the facility's policy requiring such documentation. Furthermore, outdated medications were discovered on multiple medication carts and in a medication storage room, including Albuterol inhalers, Tramadol tablets, Diclofenac Gel, and other medications with expired discard dates. The DNS confirmed that medications should be removed from stock on or before their expiration or discard after dates, as per the facility's policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, with a reported error rate of 53.85%. This was determined through observations, interviews, clinical record reviews, and document reviews. The errors involved multiple residents and included administering medications at incorrect times and incorrect dosages. Specifically, medications scheduled for 7:00 AM were administered late, beyond the one-hour window allowed by the facility's policy. One resident was administered medications at 8:15 AM, including Vitamin D, Loratadine, Fish Oil, Multivitamin, Fluticasone, Thiamine, and Lisinopril, all of which were scheduled for 7:00 AM. Another resident self-administered Fluticasone nasal spray without a physician's order or safety evaluation, resulting in an incorrect dosage. A third resident received Baclofen, Sertraline, Docusate Sodium, Gabapentin, and Quetiapine at 8:34 AM, all scheduled for 7:00 AM. Lastly, a fourth resident was given two tablets of Cyanocobalamin instead of one, as per the physician's order. The Director of Nursing Services (DNS) confirmed the expectation that medications should be administered within one hour of the scheduled time and that residents could self-administer medications only with a physician's order and safety evaluation. The facility lacked a policy defining medication errors, and the Executive Director acknowledged that errors included wrong time and dose administration. The LPN involved admitted to running behind schedule during the morning medication pass, contributing to the late administration of medications.
Failure to Respect Resident's Self-Determination
Penalty
Summary
The facility failed to respect a resident's right to self-determination by not informing a new Certified Nursing Assistant (CNA) of the resident's preference not to be disturbed for care during the night. This oversight led to an incident where the CNA attempted to turn the resident despite the resident's request to stop, resulting in bruising on the resident's thigh. The resident, who had been admitted with conditions including arthritis, hypertension, and chronic obstructive pulmonary disease, had a care plan specifying that they should not be awakened for rounds and would use the call light if assistance was needed. The incident was reported to the State Agency as a Facility Reported Incident, and the resident alleged rough care by the CNA, who was identified by the resident. The Executive Director confirmed that the CNA was not informed of the resident's wishes, which contributed to the incident. The facility's policy on resident rights emphasizes the right to a dignified existence and self-determination, which was not upheld in this case. The incident was under investigation, and the Executive Director acknowledged the failure to communicate the resident's preferences to the CNA.
Facility Fails to Maintain Quiet Environment During Night Shift
Penalty
Summary
The facility failed to ensure a comfortable, homelike environment for a resident who reported being disturbed by loud and disruptive staff during the night shift. The resident, who had a history of generalized anxiety disorder and insomnia, expressed concerns about being woken up by staff talking loudly in the hallways about personal matters and other residents' care. Despite being moved to a different room away from the nurses' station, the noise level did not improve, leading to frustration and sleep disturbances for the resident. The facility's grievance log documented multiple complaints from the resident council about night shift staff being loud in the hallways, with grievances confirmed and marked as resolved on several occasions. The Executive Director acknowledged the issue of excessive noise at night as a known and consistent problem in the facility. Although grievances were reviewed during clinical meetings and staff were re-educated on appropriate noise levels, the facility had not conducted a root cause analysis to address the issue effectively.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for one resident, which had the potential to affect the resident's person-centered care plan. The resident was admitted with a primary diagnosis of low back pain and had a quarterly MDS assessment that inaccurately documented multiple falls. The assessment indicated two falls with no injury, one fall with injury, and two falls with major injury since the last assessment. However, the resident's progress notes only documented one fall with no injury. The MDS Coordinator, who used the Resident Assessment Instrument (RAI) Manual to guide MDS activities, confirmed the inaccuracy of the assessment, acknowledging that the resident had only one fall with no injury, contrary to what was recorded in the MDS assessment.
Failure to Provide Showers as Per Resident Preference
Penalty
Summary
The facility failed to provide showers for a resident, identified as Resident #108, as per their preference and the facility's standard practice. Resident #108, who was admitted with conditions such as spinal stenosis, chronic pain syndrome, and difficulty in walking, expressed that they did not receive showers or bed baths as expected. The resident's care plan documented a requirement for showers twice a week, but the resident preferred showers three times a week. Despite this preference, the resident only received showers once a week and did not refuse showers when offered. Interviews with facility staff, including a CNA/Shower Aid and the Director of Nursing Services (DNS), revealed that the resident was not showered as per the documented schedule due to time constraints and prioritization of residents with skin issues. The DNS acknowledged that all residents should receive showers twice a week and according to their preferences, but there was no facility policy followed related to showering. The facility's standard of practice was not provided by the DNS, indicating a lack of adherence to established procedures for activities of daily living, including showering.
Deficiencies in Wound Care, Condition Reporting, and Blood Sugar Monitoring
Penalty
Summary
The facility failed to conduct weekly evaluations of a resident's significant surgical wounds, as required by their policy. Resident #67, who was admitted with a diagnosis of an unspecified open wound of the abdominal wall, had a care plan that included weekly wound evaluations. However, the clinical record lacked evidence of these evaluations. The Director of Nursing Services (DNS) confirmed that the facility's practice did not align with their policy, as weekly evaluations were not conducted for surgical wounds, including those of Resident #67. The facility also failed to report a significant change in a resident's condition to a physician in a timely manner. Resident #36 experienced a decline in their Brief Interview for Mental Status (BIMS) score from 12 to 4, indicating a significant cognitive decline. Despite this change, the Social Worker did not perform a repeat BIMS evaluation or notify the physician, as required by the facility's protocol. Additionally, Resident #62 exhibited signs of infection, such as a low-grade fever and a red, swollen elbow, which were not reported to the physician until several days later, contrary to the facility's policy on reporting changes in condition. Furthermore, the facility did not adhere to a physician's order for blood sugar monitoring for Resident #52. The resident, who had type two diabetes mellitus, had an order for blood sugar checks four times daily. However, the Medication Administration Record (MAR) showed that blood sugar readings were marked as 'Not Applicable' for several scheduled times, indicating that the checks were not performed. The DNS confirmed that this was not in compliance with the physician's order, as the blood sugar levels were not monitored as required.
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen to a resident according to the physician's order, which was a deficiency observed during a survey. The resident, who was admitted with diagnoses including unspecified bacterial pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease with acute exacerbation, was receiving oxygen via nasal cannula. The physician's order specified that the resident should receive oxygen at two liters per minute (LPM) to maintain oxygen saturation levels above 90%. However, during observations on two separate occasions, the resident's oxygen concentrator was set at three LPM, contrary to the physician's order. The Licensed Practical Nurse (LPN) confirmed that the oxygen concentrator was set incorrectly and adjusted it to the correct flow rate of two LPM. The Director of Nursing Services (DNS) also confirmed that the nursing staff is expected to follow the physician's orders when administering oxygen, which includes adhering to the specified liter flow. The facility's policy on oxygen administration, published in December 2017, also mandates that oxygen be administered per physician order. This failure to follow the physician's order for oxygen administration was identified as a deficiency during the survey.
Failure to Identify PTSD Triggers for Resident
Penalty
Summary
The facility failed to identify triggers for a resident diagnosed with post-traumatic stress disorder (PTSD), which placed the resident at risk for re-traumatization. The resident, who was admitted with diagnoses including PTSD and chronic paranoid schizophrenia, had a care plan that documented the risk of trauma or re-traumatization. However, the care plan did not specify the resident's triggers or provide interventions tailored to the resident's experiences or preferences. The Licensed Practical Nurse (LPN) was unable to articulate where the resident's baseline behaviors were documented, indicating a lack of clear documentation and communication regarding the resident's specific needs. The Director of Nursing Services (DNS) acknowledged that the interdisciplinary team was responsible for identifying triggers for residents with PTSD and incorporating them into the care plan. However, the DNS admitted to not knowing what might trigger the resident's PTSD or what the PTSD was related to. The facility's policy on Trauma-Informed Care emphasized the importance of accounting for residents' experiences and preferences to prevent re-traumatization, yet this was not reflected in the care plan for the resident in question.
Privacy Breach and Inaccurate Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain accurate medical records, as observed during a survey. On multiple occasions, computer screens on unattended medication carts in the 100 hall displayed resident information. This was confirmed by both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN), who acknowledged that the screens should have been locked when not attended. The Director of Nursing Services (DNS) also confirmed that medication carts and computer screens should be secure when not in use. Additionally, a resident was observed standing next to an unattended medication cart with the computer displaying resident information, indicating a breach of privacy. The facility also failed to maintain accurate medical records for a resident with Alzheimer's disease and type two diabetes mellitus. The resident's Treatment Administration Record (TAR) inaccurately documented no signs of infection for an abrasion on the left elbow, despite the LPN recalling that the resident had completed antibiotics for cellulitis at the site. The LPN confirmed that the TAR was inaccurate as it did not reflect the swelling and redness noted on 10/30/2024, which led to the prescription of antibiotics. The DNS confirmed the presence of a wound on the resident's left elbow, and the facility's policy required significant abrasions to be evaluated weekly and documented, which was not accurately done in this case.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with chronic pressure ulcers, leading to a deficiency in infection prevention and control. Resident #60, who was admitted with diagnoses including type two diabetes mellitus with hyperglycemia and a stage three pressure ulcer on the right heel, had a physician's order for EBP every shift for wounds. However, observations on multiple occasions revealed that EBP signage was not posted at the entrance of the resident's room, indicating a lack of adherence to the prescribed precautions. Interviews with staff members, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), highlighted a lack of understanding and implementation of EBP. The CNA was unsure of the specific personal protective equipment required under EBP and did not perform any special precautions when caring for Resident #60. The LPN, although aware of the EBP order, did not wear the necessary personal protective equipment during wound care, mistakenly believing the resident was not on EBP. The Director of Nursing Services and the Infection Preventionist confirmed the expectation for staff to follow EBP orders and acknowledged the oversight in posting the required signage.
Failure to Administer Influenza Vaccine After Consent
Penalty
Summary
The facility failed to administer an influenza vaccine to a resident, despite having received consent from the resident's guardian. The resident, who was admitted with chronic obstructive pulmonary disease, type II diabetes mellitus, and adult failure to thrive, had a signed consent form dated 10/29/2024, indicating the guardian's approval for the influenza vaccine. The facility's policy required annual influenza vaccination for residents, and the guardian was provided with the necessary vaccine information and education. However, the clinical record for the resident did not show any evidence of the vaccine being administered. The Infection Preventionist confirmed that the vaccine was not given, acknowledging that it should have been administered on the day consent was obtained. This oversight left the resident without the intended protection against influenza, as documented in the facility's updated policy.
Failure to Prevent Resident Abuse and Neglect
Penalty
Summary
The facility failed to prevent resident-to-resident abuse for seven residents and employee-to-resident neglect for one resident. Resident #13 experienced an unwitnessed fall resulting in a fractured left hip, which was not reported or assessed by nursing staff until two days later. The Hospitality Aide and CNA who found Resident #13 on the floor did not report the incident, believing the resident had placed themselves on the floor to pray, as was their behavior. This lack of reporting and assessment led to a delay in medical attention for Resident #13, who was eventually hospitalized for the injury. Resident #14 pushed Resident #15, causing them to fall to the floor, and later hit Resident #22 on the arm twice. Resident #16 hit Resident #17 after Resident #17 grabbed the back of Resident #16's wheelchair, and Resident #17 retaliated by hitting Resident #16 in the back. Resident #18 hit Resident #19 on the cheek and mouth with a closed fist during an activity. Resident #20 swatted Resident #21's hand away and threw a coffee cup at Resident #21's chest. Resident #28 attempted to take Resident #16's food tray, leading Resident #16 to push Resident #28, causing a fall and a small abrasion. The facility's policies on resident fall response and abuse prevention were not followed in these incidents. The policies required that residents who have fallen should not be moved and should be assessed by a licensed nurse, and that residents have the right to be free from abuse. The failure to adhere to these policies resulted in multiple instances of resident-to-resident abuse and neglect, highlighting significant lapses in the facility's care and reporting procedures.
Failure to Implement Post-Fall Interventions
Penalty
Summary
The facility failed to ensure post-fall interventions were implemented and followed for a resident identified as a high fall risk. The resident, who had a history of traumatic brain injury, epilepsy, and other significant medical conditions, was found on the floor with the mattress from the bed. Despite being assessed and showing no apparent injury initially, the resident was later sent to the hospital where leg fractures were discovered. The care plan for the resident included fall mats on each side of the bed, but these were not in place during a subsequent observation, indicating a failure to follow the prescribed fall precautions. The Licensed Practical Nurse (LPN) and the Administrator both confirmed that the resident was supposed to have fall mats as a precautionary measure. However, the mats were mistakenly placed by the resident's roommate's bed instead. This oversight was acknowledged by the Nurse Supervisor, who explained that staff had read the care plan for the wrong resident. The facility's policy on Resident Fall Response, which mandates proper interventions and regular checks to ensure these interventions are in place, was not adhered to in this case.
Failure to Report and Assess Resident Fall
Penalty
Summary
The facility failed to ensure a Licensed Nurse provided care for a resident after a fall. A Hospitality Aide and a Certified Nursing Assistant (CNA) did not notify a Licensed Nurse of the resident's fall, which resulted in the resident not being assessed or given medical attention until two days later. The resident, who had multiple diagnoses including unspecified dementia and repeated falls, was found on the floor by the Hospitality Aide and was assisted back into bed by the CNA without reporting the incident to a nurse. This led to a delay in the resident receiving an x-ray and subsequent hospitalization for a fractured left hip. The facility's policy required that residents who have fallen should not be moved and must be assessed by a Licensed Nurse, regardless of visible injuries. The Administrator confirmed that the Hospitality Aide and CNA did not follow this policy and acted outside their scope of practice. The incident was documented in a Facility Reported Incident (FRI) final report, and the staff involved were later educated on the proper procedures for handling falls.
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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 Carson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra Basin Post Acute | 2.5 mi | — | 13 | 0 |
| Northstar Post Acute | 3.3 mi | — | 42 | 0 |
| Ormsby Post Acute Rehabilitation | 3.7 mi | — | 2 | 0 |
| Gardnerville Health & Rehabilitation Center | 13 mi | — | 1 | 0 |
| Barton Hospital D/p Snf | 19.7 mi | — | 13 | 0 |
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