Mountain View Health & Rehabilitation Center
MOUNTAIN VIEW HEALTH & REHABILITATION CENTER in CARSON CITY, NV — inspection on November 25, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Mountain View Health & Rehabilitation Center
201 Koontz Lane Carson City, NV 89701
SUMMARY STATEMENT OF DEFICIENCIES
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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