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 Nursing Center during CMS and state inspections, most recent first.
Surveyors identified deficiencies in food storage and handling, including undated and uncovered food items in the walk-in cooler and freezer, as well as expired canned food in dry storage. The Dietary Manager and Administrator confirmed that these items were not managed according to manufacturer guidelines or best-by dates.
The facility did not follow its abuse and misappropriation policies by failing to maintain complete investigation records, not immediately reporting allegations to the Administrator or designee, and not notifying law enforcement or APS in several cases. Incidents included medications found in a nurse's personal bag, possible diversion of a resident's Morphine, and concerns about a nurse's conduct during medication administration. Required documentation and timely reporting to external agencies were not completed as per policy.
A resident with chronic respiratory conditions and a physician's order for continuous oxygen was observed receiving oxygen therapy, but the admission MDS assessment failed to document this oxygen use.
Two residents were affected when baseline care plans were not developed or accurately completed within 48 hours of admission. One resident with chronic respiratory failure did not have a baseline care plan created, and another with diabetes had a care plan that failed to document their diagnosis and insulin therapy, despite physician orders. Staff interviews confirmed these omissions and clarified that the admitting nurse was responsible for timely and accurate completion.
A resident dependent on staff for bathing, with diagnoses including COPD and heart failure, did not receive scheduled showers on multiple occasions. Documentation and staff interviews confirmed that showers were missed on certain days, and alternative hygiene measures were not offered. The resident reported feeling unclean as a result.
A resident with chronic respiratory conditions was observed receiving continuous oxygen therapy via nasal cannula, but no cautionary or safety signage was posted outside the room to indicate oxygen use. Staff interviews revealed uncertainty about who was responsible for placing the signage and where it was kept, and facility leadership confirmed the signage should have been in place but was not.
A resident who was not approved for self-administration of medications was found with a tube of Hydrocortisone cream and a medication cup containing an unidentified gel left unsecured at the bedside. The resident reported using both items, one of which was brought by family, and staff interviews confirmed that medications should not have been left in the room. The DON and nurses acknowledged the error, and the administrator stated that medications are expected to be stored properly.
A nurse failed to wear a gown while administering tube feeding to a resident on Enhanced Barrier Precautions, despite facility policy requiring both gown and gloves for such high-contact care. The nurse was unsure about the application of precautions, and leadership confirmed that proper PPE should be used when signage is present.
A nurse aide engaged in a verbal altercation with a resident who had moderate cognitive impairment, raising her voice and arguing after the resident fell while attempting to use the bathroom unassisted. Multiple staff witnessed the aide's disrespectful and aggressive behavior, which caused the resident to become upset and required intervention by a nurse to de-escalate the situation.
A resident with severe cognitive impairment and a PRN order for lorazepam had two of their prescribed pills found in another resident's room. A nurse signed out and documented the pills as wasted, with another nurse signing as a witness without actually observing the waste. The medication was not administered as ordered, and required documentation was incomplete, resulting in substantiated diversion of controlled medication.
Deficient Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and handling practices. In the walk-in cooler, a box of thawed premade peanut butter and honey sandwiches was found with only the date it was placed in the cooler, and staff were unsure how long the sandwiches were safe to use after thawing. The Dietary Manager was unable to locate manufacturer guidelines for the product's shelf life after thawing. In the walk-in freezer, two bags of french toast were found without dates, and a box of frozen pizzas was left open to air, both of which the Dietary Manager acknowledged should have been dated and covered by staff. Additionally, in the dry storage room, two and a half cases of canned pureed turkey were found with a best-by date that had already passed. The Dietary Manager confirmed that these items should have been used or discarded by the best-by date. The Administrator stated that his expectation was for all food to be stored, dated, and used or discarded according to manufacturer guidelines and best-by dates.
Failure to Implement Abuse and Misappropriation Reporting and Investigation Procedures
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation policy and procedure by not maintaining complete evidence of investigations into misappropriation of property and not immediately reporting allegations of abuse to the Administrator or designee, as well as not notifying local law enforcement or Adult Protective Services (APS) for several abuse or misappropriation allegations. In one instance, medications belonging to multiple residents were found in a nurse's personal bag at the nurse's station. The facility's investigation included a statement from the nurse and interviews with alert and oriented residents, but lacked documentation such as the names and amounts of medications found. Attempts to interview the nurse were unsuccessful, and the former DON reported that documentation of her investigative actions was missing. The Administrator and Corporate Nurse were unable to account for the missing documentation or recall all investigative steps taken. In another case, an allegation of possible diversion of a resident's liquid Morphine was reported after the medication was found to be an abnormal color. The allegation was not reported to law enforcement or APS, and the Social Worker stated she did not notify these agencies because she was not instructed to do so by the Administrator. The investigation included interviews with nurses and returning the medication to the pharmacy, but the reporting requirements to external agencies were not met. The Administrator confirmed that the Compliance Officer did not instruct him to notify law enforcement or APS. A further incident involved an allegation of resident abuse related to a nurse's conduct and medication administration. The allegation was not reported to law enforcement or APS, and the initial report was not submitted within the required two-hour timeframe. The Social Worker and Administrator both indicated that reporting to external agencies was not completed because they were not instructed to do so. The investigation documentation was incomplete, and key staff involved were unavailable for interview. These failures demonstrate lapses in following the facility's own policies and regulatory requirements for reporting and investigating abuse, neglect, and misappropriation allegations.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment regarding oxygen use for one resident. The resident was admitted with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, and had a physician's order for continuous oxygen via nasal cannula at 3 liters per minute, with instructions to titrate to maintain oxygen saturation above 90%. Despite this order and an observation confirming the resident was receiving oxygen via nasal cannula, the admission MDS did not reflect the resident's oxygen use.
Failure to Develop and Accurately Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with chronic respiratory failure and hypoxia. Upon review, it was found that no baseline care plan was present in the resident's medical record. Staff interviews revealed that the responsibility for completing baseline care plans fell to the admitting nurse, especially during weekends. The Director of Nursing noted that computer system changes during a facility acquisition contributed to the issue, but confirmed that the admitting nurse was still responsible for ensuring the care plan was completed. Additionally, the facility did not ensure that a baseline care plan accurately addressed insulin use for a newly admitted resident with diabetes. The baseline care plan for this resident did not indicate the diagnosis of diabetes or the administration of insulin, despite physician orders for insulin therapy. The Admission/Discharge Nurse acknowledged the omission, and both the DON and Administrator confirmed that baseline care plans are expected to accurately reflect residents' diagnoses and medications.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for activities of daily living due to chronic obstructive pulmonary disease, heart failure, and deconditioning, did not receive scheduled showers as required by her care plan. The resident was assessed as having intact cognition and required staff assistance for showering and transfers. Her care plan specified showers twice weekly, on Wednesdays and Saturdays, but documentation and interviews revealed that she did not receive her scheduled Saturday showers for at least three consecutive weeks. The master shower schedule and point of care documentation confirmed the absence of Saturday showers, and the resident reported that staff did not offer alternative hygiene measures, such as a bed bath or hair washing, when a shower was missed. Observations showed the resident with uncombed, greasy hair, and she expressed feeling unclean and uncomfortable due to missed showers. Staff interviews corroborated the resident's account, with one nurse aide confirming the resident did not refuse care and that scheduled showers were not always provided. The Administrator in Training and the Administrator both acknowledged the lack of documentation and confirmed that showers were not given as scheduled. The deficiency was based on the facility's failure to provide care and assistance with bathing for a resident who was unable to perform this activity independently.
Failure to Post Oxygen in Use Signage for Resident Receiving Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary and safety signage outside the room of a resident who was receiving continuous supplemental oxygen therapy. The resident, admitted with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, had a physician's order for continuous oxygen via nasal cannula. Observations on two separate days confirmed that the resident was receiving oxygen through a concentrator, but there was no signage posted outside the room to indicate that oxygen was in use. Interviews with nursing staff and facility leadership revealed a lack of clarity and follow-through regarding responsibility for placing the required oxygen signage. The nurse assigned to the hallway was unaware of the location of the signage, and the DON stated that the admitting nurse or any nurse could place the signage but was unsure why it had not been done. The Administrator also acknowledged that the signage should have been in place but did not know why it was missing.
Unsecured Medications Left at Bedside for Non-Authorized Resident
Penalty
Summary
A deficiency occurred when a resident, admitted with costochondritis and assessed as cognitively intact, was found to have medications stored unsecured at the bedside. The resident had not been approved for self-administration of medications, as documented in the assessment, and physician orders required staff to administer Diclofenac Sodium gel. Despite this, observations revealed a tube of Hydrocortisone cream and a medication cup containing a whitish gel-like substance left in the resident's room. The resident reported using both the Hydrocortisone cream, which was brought by family, and the unidentified gel, which she applied daily for pain but could not name. Staff interviews confirmed that medications should not have been left in the resident's room, as she was not authorized for self-administration. The DON was unable to identify the substance in the medication cup but stated it should not have been present, and nurses on duty denied leaving or noticing the medications at the bedside. The administrator confirmed the expectation that medications be stored appropriately, but the medications remained accessible to the resident in violation of facility policy and professional standards.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
Facility staff failed to follow established infection control procedures when a nurse did not don a gown while administering a tube feeding to a resident who was under Enhanced Barrier Precautions. The facility's policy required staff to wear both gowns and gloves when performing high-contact care activities, such as tube feedings, for residents with devices like feeding tubes. During an observation, the nurse entered the resident's room, which had signage indicating Enhanced Barrier Precautions, washed her hands, and put on gloves but did not wear a gown before administering the tube feeding. When interviewed, the nurse stated she believed a gown was not necessary for tube feeding administration and was unsure if the precautions applied to the resident or the roommate. The Infection Preventionist confirmed that the precautions were for the resident with the feeding tube and that the nurse had previously been educated on the requirements. Facility leadership clarified that staff should assume precautions apply to both residents in a shared room if there is any uncertainty, and that proper PPE should be used as indicated by signage and posted lists.
Failure to Maintain Resident Dignity During Staff Interaction
Penalty
Summary
A deficiency occurred when a nurse aide failed to treat a resident in a dignified and respectful manner. The resident, who had moderate cognitive impairment and required assistance with toileting and transfers, attempted to go to the bathroom unassisted and subsequently fell. Following the fall, the nurse aide engaged in a verbal altercation with the resident, raising her voice, yelling, and arguing with him in the presence of other staff. Witnesses reported that the nurse aide was verbally aggressive, stood over the resident, and was disrespectful and argumentative, which caused the resident to become upset. The incident was corroborated by multiple staff members who observed the nurse aide's behavior. One nurse reported that the aide screamed and cursed at the resident, while another aide described the aide as being snippy, irritable, and raising her voice. The resident was visibly upset by the interaction, and the situation required intervention by a nurse, who instructed the aide to leave the room. After the aide's removal, the resident was assisted back to bed and calmed down. The resident involved had no prior behavioral issues and had recently returned from the hospital, indicating a potentially vulnerable state. The nurse aide admitted in a written statement to raising her voice and acknowledged that the situation could have been handled better. The administrator confirmed that the staff member's conduct was disrespectful and not appropriate, regardless of any personal issues the aide may have been experiencing at the time.
Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A facility failed to protect a resident's right to be free from misappropriation of property, specifically controlled medication. A resident with severe cognitive impairment and diagnoses including depression, anxiety disorder, and dementia had a physician's order for lorazepam to be administered as needed. Two lorazepam pills, which were prescribed for this resident, were discovered in another resident's room by the Administrator in Training (AIT). The AIT reported the finding to a nurse, who took possession of the pills and stated she would waste them after her medication pass. Subsequent review of the controlled medication count sheet revealed that the nurse had signed out two lorazepam tablets for the resident and documented them as wasted, with another nurse signing as a witness. However, interviews revealed that the witnessing nurse had not actually observed the wasting of the medication and acknowledged she should not have signed the sheet. The medication administration record showed that the lorazepam had not been administered to the resident as ordered, and documentation was incomplete regarding the handling and disposal of the controlled medication. The investigation substantiated that the nurse had diverted the resident's medication, as the pills were found in another resident's room and the required documentation and witnessing of medication waste were not properly completed. The involved staff members were no longer employed at the facility at the time of follow-up interviews, and the incident was reported to the appropriate regulatory board.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Bryson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tsali Care Center | 8.1 mi | ★★★★★ | 0 | 0 |
| Skyland Care Center | 14.7 mi | ★★★★★ | 0 | 0 |
| Vero Health & Rehab Of Sylva | 14.7 mi | ★★★★★ | 7 | 0 |
| Macon Valley Nursing And Rehabilitation Center | 17.5 mi | ★★★★★ | 0 | 0 |
| Graham Healthcare And Rehabilitation Center | 21 mi | ★★★★★ | 6 | 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.