Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 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.
An RN and an LPN performed wound care on a resident with a stage 4 sacral pressure ulcer while the RN discussed another resident’s preferences and medical equipment benefits. The DON and Administrator later stated staff should not have been speaking over the resident about a different resident, and the facility policy stated residents have the right to be treated with respect and dignity.
A resident's liquid Morphine Sulfate bottle did not match the narcotic count log, with less medication in the bottle than documented. An LPN confirmed the discrepancy during a cart count, and the DON later found one dose had not been documented on the narcotic count sheet. The facility also lacked a formal process for oversight and auditing of narcotic inventory practices.
An allegation of misappropriation and possible neglect involved a resident’s Morphine Sulfate when the amount in the bottle did not match the narcotic count sheet. The DON confirmed the discrepancy and could not account for all of the missing medication, but an LPN remained on the unit with access to the medication cart and controlled substance keys after the issue was identified. The Administrator later stated the LPN should have been suspended and removed from resident care areas immediately, but that did not occur right away.
Inaccurate MDS Weight Loss Coding: A resident with dysphagia following cerebral infarction and documented weight loss had an annual MDS that incorrectly coded K0300 as if the resident were on a prescribed weight-loss regimen. The DON and MDS-LPN confirmed there was no documentation supporting that coding, and the Regional MDS Coordinator stated nurses were expected to verify MDS sections for accuracy before signing.
A resident who tested positive for COVID-19 had Droplet Precautions in place, but the clinical record lacked a care plan for the infection or precautions. Another resident with a chronic stage IV coccyx pressure ulcer had an order for wound care every other day, but the scheduled dressing change was not documented as completed, and the DON and RCM confirmed the treatment was not recorded in the chart.
Failure to complete ordered pressure ulcer treatment: A resident with a chronic stage IV coccyx wound did not have the ordered wound care documented as completed on the scheduled day. The physician ordered cleansing, skin prep, iodoform packing, and a dry dressing every other day, but the TAR and clinical record did not show the treatment was done. The RCM and DON confirmed the dressing change was not documented anywhere in the resident’s record.
An LPN worked independently on the unit before the facility could verify completed competency documentation. HR stated newly hired nurses were to complete orientation and a competency checklist before independent work, but the employee's checklist was missing from the personnel record. Six unsigned-by-employee checklists later provided had no name or other identification linking them to the LPN, and the IP could not verify the employee's competencies were evaluated.
Unsecured and Outdated Medications Found in Medication Carts: An RN left two medication bottles on top of a med cart while the cart was out of sight during med pass, and an inspection of a separate med cart found an outdated bottle of Diphenhydramine 25 mg tablets. The RN, LPN, and DON all confirmed the medications should have been secured in the cart and expired meds removed from stock.
Incomplete TAR Documentation for Ordered Monitoring: A resident with atrial fibrillation, BPH, and a Foley catheter had orders for Apixaban and every-shift monitoring for anticoagulant side effects, catheter status, and enhanced barrier precautions. The TAR lacked documentation that these ordered checks were completed, and the DON confirmed the nurse did not complete the TAR as expected.
An LPN entered the rooms of two residents with confirmed COVID-19 without the required eye protection, gown, or gloves, despite signage and orders for droplet/contact precautions. During wound care for a resident with a stage IV coccyx pressure ulcer, an RN donned PPE in the wrong order, changed gloves without hand hygiene after cleaning a bowel movement, handled supplies before hand hygiene, and left the room wearing the isolation gown while returning to the wound cart.
Failure to Screen and Educate an RN on COVID-19 Vaccine. The facility did not have documentation that an RN received COVID-19 vaccine education or screening, and the IP confirmed the RN had not been screened for eligibility to receive the vaccine. The facility stated it used the federal regulation as its policy for staff screening and education.
Two employees did not complete required initial dementia-related behavioral health training within the first 30 days of hire. A CNA and an SLP both received the training well after the facility’s stated timeframe, and HR confirmed the delay during interview. Facility policy required dementia management and behavioral health training during new employee orientation or within the first 30 days of employment.
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.
Resident Not Treated With Dignity During Wound Care
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when staff discussed another resident’s preferences during wound care for Resident #2. Resident #2 was admitted and later readmitted with diagnoses including a stage 4 sacral pressure ulcer and major depressive disorder, recurrent, unspecified. During an observed dressing change on Resident #2’s pressure ulcer, an RN and an LPN stood on either side of the resident while the RN began talking about how a type of medical equipment was beneficial for a different resident. Later, the DON and Administrator stated that staff should not have been speaking over the resident about another resident and that discussing a situation involving a different resident while providing treatment to Resident #2 would not be dignified treatment. The facility policy titled Notice of Resident Rights Under Federal Law stated that the resident had the right to be treated with respect and dignity.
Narcotic Count Discrepancy for Resident Morphine
Penalty
Summary
The facility failed to ensure a resident was free from misappropriation of personal property when the amount of liquid Morphine Sulfate remaining in a medication bottle did not match the amount documented in the narcotic logbook. Resident #24 was admitted and later readmitted with diagnoses including Alzheimer's disease with late onset and unspecified low back pain, and had a physician's order for Morphine Sulfate oral solution 100 mg/5 ml, 0.25 ml by mouth every four hours as needed for pain or shortness of breath. During inspection of the station 1C medication storage cart, a bottle labeled for Resident #24 was found with 24 ml remaining, while the narcotic count sheet documented 24.75 ml remaining. The LPN confirmed the bottle contained less medication than the narcotic count sheet reflected and stated controlled substances were counted at shift change by two nurses. The DON reviewed the count sheet and confirmed the discrepancy, then found that one dose of Morphine Sulfate administered in March 2025 had not been documented on the narcotic count sheet. The DON also confirmed the facility did not have a formal process for oversight and frequency of auditing narcotic inventory practices, and the Administrator stated the discrepancy was being investigated for misappropriation of resident property and possible neglect.
Delayed Response to Controlled Substance Discrepancy
Penalty
Summary
The facility failed to implement its policies related to misappropriation of resident property, abuse, and neglect in a timely manner after an allegation involving Resident #24’s Morphine Sulfate. Resident #24 was admitted and later readmitted with diagnoses including Alzheimer’s disease with late onset and unspecified low back pain. The resident had a physician’s order for Morphine Sulfate oral solution 100 mg/5 ml, with 0.25 ml ordered every four hours as needed for pain or shortness of breath. During inspection of the station 1C medication storage cart, surveyors found a bottle of liquid Morphine Sulfate labeled for Resident #24 with 24 ml remaining, while the narcotic count sheet documented 24.75 ml remaining. The LPN confirmed the amount in the bottle was less than the amount listed on the count sheet. The DON reviewed the narcotic count sheet and confirmed the discrepancy, then stated the bottle would be investigated. The DON later reviewed the record and found one dose of Morphine Sulfate administered in March 2025 had not been documented on the narcotic count sheet, accounting for 0.25 ml, but could not find documentation accounting for the additional 0.5 ml missing from the bottle. The report also documented that the LPN remained on the unit with possession of the medication cart keys, including the key to the controlled substance drawer, after the discrepancy was identified. The Administrator stated the discrepancy was being investigated for misappropriation of resident property and possible neglect, and that corporate leadership had instructed suspension of the LPN, but the suspension had not yet occurred. The Administrator later confirmed the LPN was not suspended and removed from resident care areas immediately after the discrepancy was identified and the DON could not account for it. Facility policies stated that allegations of misappropriation, abuse, and neglect required immediate protection of the resident and immediate suspension and/or removal of the alleged perpetrator from resident care areas.
Inaccurate MDS Weight Loss Coding
Penalty
Summary
The facility failed to ensure the accuracy of Resident #74’s annual MDS assessment. Resident #74 was admitted and later readmitted with diagnoses including dysphagia following cerebral infarction, conversion disorder with seizures or convulsions, and epilepsy. The resident’s weights declined from 107.0 pounds on 01/13/2025 to 102.0 pounds on 02/17/2025 and 99.0 pounds on 03/17/2025. A physician progress note dated 02/02/2025 documented dysphagia following cerebral infarction and abnormal weight loss, with orders for mirtazapine 7.5 mg at bedtime, weekly weights, monitoring oral intake, and dietitian follow-up. A Clinically Unavoidable Review and Acknowledgment for Weight Loss signed on 03/11/2025 documented that the weight loss was unavoidable related to neurological disease, and a physician note dated 03/24/2025 documented abnormal weight loss and an eight-pound loss from January to March 2025. The annual MDS assessment coded section K0300, Weight Loss, as yes for loss of 5 percent or more in the last month or loss of 10 percent or more in the last 6 months, and documented that the resident was on a prescribed weight-loss regimen. The DON confirmed the resident had dysphagia following cerebral infarction and had not been on a prescribed weight loss program. The MDS-LPN confirmed the coding was incorrect and stated there was no documentation that the resident had been on a prescribed weight loss program. The MDS-LPN also confirmed the facility followed the RAI Manual, and the Regional MDS Coordinator stated nurses were expected to review and verify MDS sections for accuracy before signing.
Missing COVID-19 Care Plan and Unimplemented Pressure Ulcer Treatment
Penalty
Summary
A comprehensive care plan was not developed for Resident #108 after the resident tested positive for rapid antigen coronavirus on 01/11/2026. The resident was admitted and readmitted with acute systolic heart failure, and a physician’s order documented Droplet Precautions for COVID-19 for 10 days. The clinical record did not contain a care plan related to the COVID-19 infection or the use of Droplet Precautions. On 01/12/2026, a sign was posted at the room doorway indicating Special Droplet/Contact Precautions, and PPE supplies were placed at the door. An LPN later stated that Droplet Precautions were used for residents with confirmed COVID-19 infection, and the DON stated that care plans should be reviewed and updated continuously and that Resident #108 should have had a care plan related to the COVID-19 infection and Droplet Precautions. Resident #2’s care plan for a stage IV coccyx pressure ulcer was not implemented as ordered. The resident was admitted and readmitted with diagnoses including a stage four pressure ulcer of the sacral region and major depressive disorder. A skin evaluation documented a stage IV pressure ulcer on the coccyx with measurements of 0.9 cm by 0.7 cm by 0.5 cm. The physician’s order and TAR directed wound care every other day, including cleansing the wound, applying skin prep to the peri-wound area, packing with iodoform strip, and covering with a dry dressing. The January 2026 TAR showed the wound care was due on 01/12/2026, but it was not documented as completed. The care plan, revised on 12/02/2025, identified the chronic stage IV coccyx wound and stated treatment would be completed as ordered, yet the RCM and DON confirmed the dressing change ordered for 01/12/2026 was not documented anywhere in the resident’s clinical record.
Failure to Complete Ordered Pressure Ulcer Treatment
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with a chronic stage IV coccyx pressure ulcer. The resident was admitted and later readmitted with diagnoses including stage four pressure ulcer of the sacral region and major depressive disorder. A skin evaluation dated 01/09/2026 documented a stage IV pressure ulcer on the coccyx measuring 0.9 cm by 0.7 cm by 0.5 cm, and the resident stated on 01/12/2026 that the resident had a wound. A physician's order and the TAR directed staff to cleanse the coccyx pressure ulcer, apply skin prep to the peri-wound, pack the wound with iodoform packing strip, and cover with a dry dressing every other day, with the order starting 11/29/2025. The January 2026 TAR showed the wound care should have been completed on Monday 01/12/2026, but it was not documented as completed that day. The care plan, revised on 12/02/2025, identified the resident as having a chronic stage IV coccyx wound and being at risk for further skin breakdown, with treatment to be completed as ordered. The RCM and DON both confirmed that the dressing change due on Monday was not documented anywhere in the resident's clinical record.
LPN Worked Independently Without Verifiable Competency Documentation
Penalty
Summary
The facility failed to ensure that 1 of 20 sampled employees had the specific competencies and skill sets necessary to care for residents' needs. Employee #15 was hired as an LPN and worked on the 100's unit on 01/10/2026 and 01/11/2026. Human Resources stated that newly hired nursing staff with prior experience were to complete a two-week orientation with skills education, on-the-floor and in-office experience, and a competency checklist reviewed by nursing management before being scheduled to work independently. HR also stated that as-needed nurses should still receive some orientation and a completed competency checklist before working. HR reported that Employee #15's first independent shift occurred on 01/10/2026, and HR observed the employee working in the 100's unit without supervision on 01/10/2026 and 01/12/2026. Employee #15's competency checklist was not present in the personnel record. When HR contacted the Staff Development LPN/Infection Preventionist, the IP did not believe the checklists were in the file. HR later provided six competency checklists and stated they belonged to Employee #15, but the forms had no name or other identification showing ownership and were signed only by the IP. The IP stated the facility required newly hired employees to write their own name on the top of competency checklists to authenticate ownership, and the IP could not verify that Employee #15's competencies had been evaluated.
Unsecured and Outdated Medications Found in Medication Carts
Penalty
Summary
Medications were not kept secured when an RN left two bottles of medication, Sodium Bicarbonate and Vitamin D3, on top of a medication cart during the morning medication pass. The RN locked the cart and entered a resident's room while the cart was in the hallway and not within sight, leaving the bottles accessible on top of the cart. Later, the RN confirmed the medications had remained on top of the cart while the cart was out of view and stated medications were to be placed back in the cart and the cart locked when not within sight of the nurse. The DON also stated it would not be appropriate to leave medications on top of the cart when it was not within eyesight of the nurse. Outdated medication was also found in 1 of 4 medication carts inspected. During inspection of the medication storage cart at the nurses' station on the 300 unit, a bottle of allergy relief Diphenhydramine 25 mg tablets was found, and the expiration date on the bottle had passed. An LPN confirmed the medication was outdated and stated expired and discontinued medications were to be removed from the medication cart and placed in a cabinet designated for medication destruction. The DON stated expired and discontinued medications were to be removed from medication storage carts, and the facility policy required outdated, contaminated, discontinued, or deteriorated medications to be removed from stock and disposed of according to procedure.
Incomplete TAR Documentation for Ordered Monitoring
Penalty
Summary
The facility failed to complete the Treatment Administration Record (TAR) for Resident #14’s ordered monitoring of anticoagulant side effects, Foley catheter monitoring, and enhanced barrier precautions. Resident #14 was admitted with diagnoses including unspecified atrial fibrillation, benign prostatic hyperplasia with lower urinary tract symptoms, and other obstructive and reflux uropathy. The record showed an order for Apixaban 5 mg by mouth twice daily for atrial fibrillation, along with orders for every-shift monitoring for bleeding, bruising, black tarry stools, red urine, sudden severe headache, and Foley catheter-related monitoring and enhanced barrier precautions. Resident #14’s TAR dated 01/10/2026 lacked documentation that the anticoagulant side effect monitoring, Foley catheter monitoring, and enhanced barrier precautions had been completed. On 01/15/2026 at 2:22 PM, the DON confirmed the TAR had not been completed by the nurse. The DON stated 01/10/2026 had been the nurse’s first day working alone on the floor and expected the documentation to have been completed on the TAR. The facility policy stated that after treatment administrations, the nurse would sign after the treatment and double check the TAR for needed signatures or initials prior to leaving the shift.
PPE and Hand Hygiene Not Followed During COVID-19 Room Entry and Wound Care
Penalty
Summary
Staff failed to wear the required PPE when entering the rooms of two residents with confirmed COVID-19 infections. Resident #108 was admitted and readmitted with acute systolic heart failure and tested positive for COVID-19 on 01/11/2026. Although a sign at the doorway indicated Special Droplet/Contact Precautions and required hand hygiene, a face mask, eye protection, gown, and gloves, an LPN entered the room wearing only an N95 respirator and did not don eye protection, gown, or gloves. The LPN later returned to the doorway, reviewed the signage, changed the respirator, and then left the area after using sanitizer. Resident #58 was admitted and readmitted with a diagnosis of COVID-19 and tested positive on 01/07/2026. A Droplet/Contact Precautions sign and PPE organizer were posted at the room entrance, but the same LPN entered the room without eye protection, gown, or gloves. The LPN then stood in the doorway, took a gown from the organizer, did not don it, entered the room, and later changed respirators. The LPN stated that staff were to don an N95 respirator, gown, and gloves before entering the room of a resident with confirmed COVID-19, and the Infection Preventionist stated PPE was expected before room entry to limit exposure and prevent a larger outbreak. Enhanced barrier precautions and hand hygiene were not appropriately followed during wound care for Resident #2, who had a stage IV coccyx pressure ulcer. During dressing change preparation, an RN donned gloves before a gown, touched drawers of the EBP cart, changed gloves without performing hand hygiene, and then cleaned the resident's bowel movement. The RN later handled saline vials before doffing gloves and performing hand hygiene, then completed the dressing change. The RN also exited the room while still wearing the isolation gown used during wound care to obtain additional supplies from the wound cart. The RN acknowledged not donning PPE in the correct order, not performing hand hygiene after cleaning the bowel movement before touching the saline vials, and not removing the gown before returning to the wound cart. The DON stated the correct order was to don a gown before gloves and that leaving the room in the gown and opening the wound cart created a risk of transferring infections because the cart stored wound care supplies for all residents.
Failure to Screen and Educate RN on COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure that a staff member received screening and education regarding the SARS Coronavirus 2019 (COVID-19) vaccine for 1 of 1 staff sampled for COVID-19 vaccine review. Employee #23 was hired as a Registered Nurse with a start date of 08/31/2023. During an interview on 01/15/2025 at 9:55 AM, the Infection Preventionist stated the facility had no documentation showing that the RN received education or screening related to the COVID-19 vaccine and confirmed the RN had not been screened for eligibility to receive the vaccine. The Infection Preventionist also stated the facility used the federal regulation as its policy for screening and educating staff on the COVID-19 vaccine.
Delayed Dementia Behavioral Health Training for New Employees
Penalty
Summary
The facility failed to ensure initial behavioral health care training related to dementia was completed within the required timeframe for 2 of 20 sampled employees. Employee #9 was hired as a CNA on 06/16/2025, but the personnel record showed the initial dementia behavioral health training was not completed until 11/01/2025. Employee #10 was hired as a Speech Language Pathologist on 06/27/2025, but the personnel record showed the initial dementia behavioral health training was not completed until 10/30/2025. During interview on 01/15/2026, Human Resources/Payroll stated that all employees, contracted employees, and agency staff were required to complete behavioral health training related to dementia within the first 30 days of hire and annually thereafter. Human Resources/Payroll confirmed that Employee #9 and Employee #10 completed the initial dementia-related behavioral health training more than 30 days after hire. Facility policy titled Nursing Personnel Education and Training, published November 2016, required Licensed Nurses and CNAs to complete dementia management training, care of cognitively impaired, and behavioral health training within the first 30 days of employment, and the CMS Hand-in-Hand Toolkit policy stated dementia training for center employees, contract staff, and routine volunteers would be completed during new employee orientation.
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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Illustrative
What surveyors actually found near you
We read the 141 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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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 | — | 34 | 0 |
| Gardnerville Health & Rehabilitation Center | 13 mi | ★★★★★ | 3 | 0 |
| Barton Hospital D/p Snf | 19.7 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.