Mountain View Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mountain View Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF757Jan 19, 2022

  Based on observation, interview, and record review, the facility failed to ensure resident's drug regimen be free from unnecessary drugs for one (Resident #1) of 13 residents reviewed. The facility failed to ensure Resident #1's anticoagulant medication was not administered without adequate monitoring of lab results which resulted in resident #1 being sent to ER and diagnosed with a supratherapeutic INR of 11 (above thereapeutic level of blood thinning), [CONDITION(S)] from possible GI bleed, was hospitalized and received a plasma transfusion. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 1/18/22. […]

• Immediate jeopardy, isolatedF656Nov 17, 2025

  Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs for 1 of 7 residents (Resident #1) reviewed for care plans.The facility failed to implement Resident #1's comprehensive person-centered care plan for repositioning assistance by two staff members. On 11/11/25, CNA A repositioned the resident alone. During the process, the resident rolled off the bed and struck his head on the suctioning machine suffering from a brain bleed, sustaining a 2 cm laceration above the right eyebrow, orbital fracture, and sinus fracture. The noncompliance was identified as PNC. The IJ began on 11/11/25 and ended 11/11/25. […]

• Immediate jeopardy, isolatedF689Nov 17, 2025

  Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 7 residents reviewed for accidents and supervision.Resident #1 required two-person assistance for peri care and repositioning. On 11/11/25, CNA A repositioned the resident alone. During the process, the resident rolled off the bed and struck his head on the suctioning machine, causing for him to suffer a brain bleed, sustaining a 2 cm laceration above the right eyebrow, orbital fracture, and sinus fracture. The noncompliance was identified as PNC. The IJ began on 11/11/25 and ended 11/11/25. […]

• Immediate jeopardy, isolatedF600May 5, 2025

  Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 9 residents (Residents #1) reviewed for neglect. The facility failed to coordinate care and services with the hospice provider to ensure the written plans of care included both the most recent hospice plan of care and a description of the services furnished by the nursing facility to prevent neglect. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. […]

• Immediate jeopardy, isolatedF689May 5, 2025

  Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent for 1 of 9 residents (Residents #1) reviewed for accidents. The facility failed to ensure the Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. The resident sustained a 2 cm laceration to the right side of the forehead and a dense fracture of C1 and C2 (a broken bone in the neck, specifically on second vertebra, breaks at its base). An Immediate Jeopardy (IJ) situation was identified on 05/02/25. […]