Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain View Manor during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of wandering entered another resident's room at night, causing emotional distress and prompting a police response. Despite care planning and interventions such as frequent monitoring and redirection, staff were unable to prevent the incident, and interviews confirmed that wandering into other rooms was a known issue.
Two residents with cognitive impairments were repeatedly observed engaging in sexual behaviors without adequate assessment of their capacity or consent. Staff redirected and separated the residents but did not notify a physician or conduct formal evaluations to determine decision-making ability or consent, and there was inconsistent documentation of POA involvement. Facility policy requiring investigation and reporting of suspected sexual abuse was not followed.
Two residents with cognitive impairments engaged in sexual contact without adequate assessment of capacity or consent. Staff observed and documented multiple incidents, redirected and separated the residents, but did not notify physicians or legal representatives, nor report the incidents as possible sexual abuse to the state agency. Required assessments and investigations were not completed, contrary to facility policy.
Two residents with cognitive impairments engaged in repeated sexual contact, including inappropriate touching, without evidence that the facility assessed their capacity to consent or notified their physicians. Staff documented and attempted to redirect the behaviors but did not conduct a formal investigation or consistently notify legal representatives, in violation of facility policy requiring thorough investigation and reporting of all suspected abuse.
A resident with a history of dementia and cognitive decline was not assessed for elopement risk upon re-admission, nor was a care plan developed despite worsening cognitive status. The resident exited the facility through a door with a faulty locking mechanism and was found outside with injuries. Staff relied on verbal communication for monitoring elopement risk, and facility policy requiring assessment and intervention was not followed.
Failure to Prevent Resident Wandering and Room Entry
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with moderate cognitive impairment and a history of wandering from entering another resident's room. The resident, who was identified as an elopement risk and had impaired safety awareness, was care planned for frequent monitoring and diversional interventions. Despite these interventions, the resident was able to wander into another resident's room during the night. The incident involved a resident with a history of traumatic brain injury and moderate cognitive impairment, who was approached in her room by the wandering resident. The resident who entered the room was wearing only a diaper brief and was observed touching the other resident's walker, causing the resident in bed to feel unsafe and emotionally distressed. The event was witnessed by staff, and the resident who felt threatened called 911, resulting in a police report being filed. Staff interviews confirmed that wandering into other residents' rooms was a known issue for certain residents, and staff described various redirection techniques. However, the incident demonstrated that the interventions in place were not sufficient to prevent the wandering resident from entering another resident's room and causing emotional distress. Facility documentation and staff statements indicated that monitoring and redirection were not consistently effective in preventing such incidents.
Failure to Assess Capacity and Consent in Resident Sexual Contact
Penalty
Summary
The facility failed to implement its policy regarding sexual contact between two residents who were not adequately assessed for capacity and consent. Multiple incidents occurred in which two residents with cognitive impairments were observed engaging in sexual behaviors, including kissing and inappropriate touching, in common areas of the facility. Staff redirected the residents and separated them, but there was no evidence that a physician was notified to assess the residents' decision-making abilities or that a formal assessment was conducted to determine if the sexual contact was consensual. One resident had a history of peripheral vascular disease, unspecified dementia, anxiety disorder, and other medical conditions, with BIMS scores indicating moderate to severe cognitive impairment. The resident had a medical POA, but there was no documentation that the POA was contacted or that a physician evaluated the resident's capacity to consent to sexual activity. The other resident had diagnoses including unspecified dementia, schizophrenia, and major depressive disorder, with care plans indicating impaired cognitive function and a need for assistance with decision-making. Although a BIMS score at one point indicated intact cognition, staff assessments and care plans noted moderate impairment and the need for cues and supervision. There was inconsistent documentation regarding the notification of the resident's POA and physician, and no evidence of a capacity or consent assessment following the incidents. Interviews with facility staff, including the ADON, DON, and social services, revealed a lack of clarity and follow-through regarding the required steps for investigating possible sexual abuse or inappropriate sexual contact. Staff acknowledged that incidents were not reported as allegations of possible sexual abuse, and there was no investigation or documentation to determine the residents' ability to consent. The facility's abuse prevention policy required reporting and investigation of all suspected abuse, including sexual abuse, but these procedures were not followed in the cases involving these two residents.
Failure to Report and Assess Capacity in Resident Sexual Contact
Penalty
Summary
The facility failed to report to the state agency incidents involving two residents who engaged in sexual contact without adequate assessment of their capacity and consent. Both residents had documented cognitive impairments, with one resident showing moderate to severe cognitive decline and the other having a history of dementia and psychiatric diagnoses. Despite multiple documented incidents of sexual contact, including inappropriate touching and public displays of affection, there was no evidence that the facility conducted or documented a physician-led assessment to determine the residents' decision-making abilities or whether the contact was consensual. Staff observed and documented several incidents where the two residents were engaged in sexual behaviors, including holding hands, kissing, and inappropriate touching. Staff attempted to redirect the residents and eventually separated them by moving one to another hallway. However, there was no documentation that the residents' physicians or their legal representatives were notified at the time of the incidents to assess capacity or consent. Additionally, the facility did not initiate an investigation or report the incidents as possible sexual abuse to the state agency, as required by facility policy and state regulations. Interviews with facility staff, including the ADON, DON, and administrator, revealed a lack of clarity and follow-through regarding the reporting and investigation process for potential sexual abuse. Staff acknowledged that the incidents should have been reported and investigated, and that assessments of capacity and consent were not completed. The facility's own abuse prevention policy requires immediate reporting and investigation of any suspected abuse, including sexual contact where consent is unclear, but these procedures were not followed in this case.
Failure to Investigate and Assess Capacity in Resident Sexual Contact
Penalty
Summary
The facility failed to investigate and assess the capacity and consent of two residents involved in repeated sexual contact. Both residents had documented cognitive impairments, with one resident exhibiting moderate to severe cognitive decline and the other having a history of dementia, schizophrenia, and other mental health conditions. Despite multiple incidents of sexual contact, including inappropriate touching and public displays of affection, there was no evidence that the facility conducted a formal assessment of either resident's ability to consent or notified their physicians to determine decision-making capacity. Staff observed and documented several incidents where the residents engaged in sexual behaviors, including holding hands, kissing, and inappropriate touching. These incidents were noted in clinical records and staff notes, and staff attempted to redirect the residents and separate them by moving one to a different hallway. However, there was no documentation of a thorough investigation into whether the sexual contact was consensual, nor was there evidence that the residents' legal representatives or physicians were consistently notified at the time of the incidents. The facility's own policy required that all allegations or suspicions of abuse, including sexual abuse, be reported and investigated, but this process was not followed. Interviews with facility staff, including the ADON, DON, and social services, revealed uncertainty about whether assessments for capacity or consent were performed. Staff acknowledged that the residents had cognitive impairments and that one had a POA, but could not provide evidence of physician involvement or formal investigations. The administrator and DON both stated that incidents of possible sexual abuse should be investigated and that residents should be protected during such investigations, but there was no documentation that these steps were taken. The facility also failed to report the incidents as required by policy and state law.
Failure to Assess and Supervise Resident at Risk for Elopement
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from accident hazards and provided with adequate supervision to prevent an elopement incident. The resident, who had a history of peripheral vascular disease, unspecified dementia, anxiety disorder, paroxysmal atrial fibrillation, polyneuropathy, alcohol abuse, tobacco use, and long-term use of anticoagulants, was readmitted to the facility without evidence of an elopement risk assessment at the time of re-admission. Although an elopement risk tool completed months later indicated no cognitive deficits, subsequent assessments showed a decline in cognitive status, with a BIMS score indicating severe cognitive impairment. There was no documentation of a re-assessment of elopement risk following this decline, nor was there an elopement risk care plan in place prior to the incident. The incident occurred when the resident was found missing during staff rounds and was later located outside the facility, on the ground in the parking lot, away from his wheelchair. The resident sustained a cut over the right eye and abrasions to the right ankle and foot. Staff interviews revealed that the door through which the resident exited was supposed to be locked and required a code to open, but it was discovered that the door's locking mechanism was faulty, and it may not have been properly closed after use. Staff also indicated that communication about residents at risk for elopement was typically done verbally, and there was no formal documentation or care plan addressing the resident's elopement risk prior to the incident. Facility policy required that all residents be assessed for elopement risk upon admission and that any resident demonstrating elopement behaviors be immediately considered at risk, with appropriate interventions implemented. However, the facility failed to follow this policy for the resident in question, as there was no evidence of timely elopement risk assessment or care planning in response to the resident's cognitive decline. The lack of proper assessment, documentation, and supervision contributed to the resident's ability to exit the facility unsupervised and sustain injuries.
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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.
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Nursing homes near Prescott
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Granite Creek Health & Rehabilitation Center | 3 mi | ★★★★★ | 5 | 0 |
| Prescott Village Nursing & Rehabilitation | 3 mi | ★★★★★ | 18 | 0 |
| Haven Health Prescott, Llc | 3.7 mi | ★★★★★ | 0 | 0 |
| Prescott Valley Nursing & Rehabilitation | 7.4 mi | ★★★★★ | 3 | 0 |
| Haven Of Cottonwood | 26.1 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.