Mountain View Rehab: Resident Fell After Staff Warning - PA
That sequence, documented in a federal inspection completed September 17, 2025, formed the basis of a deficiency citation at the "actual harm" level, the second-most serious category in the federal rating system.
The warning on September 5 was not a subtle one. According to the facility's own incident and accident documentation, a licensed practical nurse identified as Employee 5 had seen the aide, identified as Employee 1, running in a hallway while pushing a different resident in a wheelchair. That resident also had no leg rests attached. The nurse stopped the aide and spoke with them directly. A supervisor identified as Employee 4 then followed up with formal instruction: never push a resident without leg rests, never push a resident very fast. The documentation recorded that Employee 1 was trained on giving care with caution and patience, on proper transport technique, and specifically on the use of leg rests.
That was September 5.
On September 6, Employee 1 was pushing Resident CR1 in a wheelchair with no leg rests in place. CR1 fell. The inspection report does not describe the nature of the injury in detail, but federal reviewers classified the outcome as actual harm to the resident.
The administrator and director of nursing, interviewed together on September 17 at 12:31 p.m., confirmed the timeline to inspectors. They acknowledged that Employee 1 had been educated the day before the fall, and that the fall happened anyway.
After CR1 fell, the facility moved quickly. Disciplinary action was taken against Employee 1. On September 6 and 7, the facility conducted full-house audits across every nursing unit and delivered education to all staff on the proper use of leg rests when pushing wheelchair residents. Follow-up audits were completed on September 10 and again on September 16, with staff checking that leg rests were in place on any chair being pushed by an employee, and that foot rests were available on the back of wheelchairs and Broda chairs even when residents self-propelled, in case staff needed to take over.
The response was thorough. It came one fall too late.
What the inspection record leaves unresolved is a simpler question: what happened between the warning on the afternoon of September 5 and the moment Employee 1 got behind CR1's wheelchair the following morning? The nurse had seen the problem. The supervisor had documented it. The aide had been told, in plain terms, what not to do. None of that stopped what happened next.
Federal inspectors cited the facility under Pennsylvania nursing home regulations governing the responsibilities of licensees, resident rights, and the adequacy of nursing services. The citation states the facility failed to ensure that staff appropriately implemented interventions to prevent falls or injury after the concern with Employee 1 had already been identified.
Resident CR1 is identified only by those initials in the inspection report. Her age, her diagnosis, the extent of her injury, and whether she recovered fully are not recorded in the document reviewed for this article. What is recorded is that she was in a wheelchair, that she had no leg rests, that she fell, and that the person pushing her had been told the day before exactly why that was dangerous.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain View Rehabilitation and Senior Living Ctr from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
MOUNTAIN VIEW REHABILITATION AND SENIOR LIVING CTR in COAL TOWNSHIP, PA was cited for violations during a health inspection on September 17, 2025.
The warning on September 5 was not a subtle one.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.