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Complaint Investigation

Mountain View Health & Rehabilitation Center

Inspection Date: November 25, 2025
Total Violations 2
Facility ID 295079
Location CARSON CITY, NV
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Inspection Findings

F-Tag F0580

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

anticoagulation with Eliquis twice daily and had developed significant bruising to the left forehead and periorbital area. Per staff, the resident was somewhat more confused than normal and continued to have significant pain in the left arm and ribs. The resident was sent to the emergency department for further workup as the resident was high risk due to having been on blood thinning medication. This was discussed with nursing. Nursing notes reviewed and stated that the provider was contacted in the night, however it was unclear what the outcome of the conversation was. On 11/25/2025 at 3:27 PM, the Director of Nursing (DON), verbalized nurses were expected to ensure contact with the NP, as necessary, and should document these communications in a progress note. On 11/25/2025 at 3:34 PM, the DON confirmed the NP was not notified of the resident's fall and injury until the day shift staff had done so later that morning.

On 11/25/2025 at 3:43 PM, the Administrator verbalized the RN was suspended for failing to ensure notification of the NP regarding Resident #2's fall. The Administrator verbalized the NP was upset the NP had not been notified sooner due to the resident having been on an anticoagulant and was considered high risk. On 11/25/2025 at 3:48 PM, the Administrator verbalized the facility could not locate a policy for physician notification related to change of condition and confirmed the Medical Director/Physician Coverage in Emergency policy dated January 2025 was in effect during the time of the incident. The facility policy titled, Fall Management and Neurological Check, updated January 2025, lacked documentation of

the notification of the physician or provider post fall. The facility policy titled, Medical Director/Physician Coverage in Emergency, dated January 2025, documented the facility staff were to contact the on-call physician, if the on-call physician was not available, the facility staff were to contact the Medical Director, if

the Medical Director was not available, the facility staff were to contact the Regional Director of Operations and the Regional Support Nurse for assistance. FRI 2579716

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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

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain View Health & Rehabilitation Center

201 Koontz Lane Carson City, NV 89701

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)

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F-Tag F0943

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Based on personnel record review, interview and document review, the facility failed to ensure initial elder abuse prevention training was completed timely for 1 of 10 sampled employees (Employee #8). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include:Employee #8Employee #8 was hired as a Certified Nursing Assistant on 11/01/2025.Employee #8's personnel record lacked documented evidence elder abuse prevention training was completed upon hire.On 11/25/2025 at 2:36 PM, the Administrator verbalized abuse training was to be completed within the first orientation. Staff were not permitted to work on the floor prior to the completion of abuse training. All staff were required to complete abuse training. The Administrator confirmed Employee #8 lacked timely elder abuse training.The facility policy titled Abuse Training, updated 10/2022, documented facility staff, contract staff and routine volunteers were trained on abuse prevention, reporting, and intervention upon hire, annually and periodically thereafter in accordance with state and federal guidelines and facility needs.

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📋 Inspection Summary

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER in CARSON CITY, NV inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CARSON CITY, NV, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MOUNTAIN VIEW HEALTH & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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