Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Care Center during CMS and state inspections, most recent first.
A resident with type 2 DM had a blood sugar of 43 mg/dL, but the ordered Glucose Gel was not administered and the MAR lacked documentation of treatment. An LPN, the Unit Manager, the DON, and a Clinical Resource Nurse confirmed the glucose was not rechecked within 15 minutes, no change-in-condition documentation was completed, and the PCP was not notified as required by standing orders and facility policy.
A resident with phantom limb pain, major depressive disorder, and dementia remained on Fluoxetine HCl 40 mg daily even after the consultant pharmacist recommended a GDR to 20 mg daily and the prescriber agreed. The signed GDR form was filed in the chart instead of being routed to the DON for review and processing, and the EMR showed no evidence the dose was reduced.
Medication Error Rate Exceeded Allowed Threshold. An LPN administered medications to a resident with GERD and HTN that did not match the physician orders, including giving aspirin in a different dosage form and losartan at 50 mg instead of the ordered 100 mg. The LPN acknowledged the discrepancies and stated the orders should have been verified before administration. The facility’s medication administration policy required staff to verify the right medication and right dosage and follow prescriber orders.
An LPN failed to maintain sanitary medication administration practices for a resident with GERD by touching aspirin with a bare finger, returning tablets that fell onto the medication cart to the original bottle, and placing a used blood glucose meter into a scrub pocket without disinfecting it. The facility also had an incomplete Legionella water management plan that lacked an illustrated flow diagram, specific monitoring details, defined corrective actions, and current review documentation, and the MD reported no written records of fixture or water heater inspections.
The facility failed to administer prescribed tube feeding orders for three residents, leading to potential nutritional deficits. A resident with a gastrostomy tube was not fully delivered the prescribed Glucerna 1.2, resulting in a shortage of 366 ml over 72 hours. Another resident on Jevity 1.5 received 403 ml less than intended, and a third resident missed 654 ml of Glucerna 1.2, impacting their calorie intake. These discrepancies were confirmed by a Registered Dietitian.
The facility failed to label and date open food products and maintain sanitary conditions in the kitchen, potentially exposing residents to foodborne illnesses. Observations included dirty coffee machines, soiled ovens, and improperly stored food items. The kitchen manager acknowledged the need for more frequent cleaning and proper labeling, which was not in line with the facility's policies.
The facility failed to implement proper infection control measures for residents requiring Enhanced Barrier Precautions (EBP). A resident with a urinary catheter and unstageable wound lacked EBP signage and PPE, leading a hospice RN to provide care without a gown. Another resident with a stage 4 pressure ulcer had EBP signage, but staff did not wear gowns or perform hand hygiene after glove removal. Additionally, the facility lacked a policy on gown reuse, with staff observed reusing gowns throughout shifts, increasing the risk of cross-contamination.
A facility failed to create a baseline care plan for a resident's Foley catheter within 48 hours of admission, despite the resident's complex medical conditions including urinary retention and neurogenic bladder. Staff interviews revealed that the DON's restrictions on care plan access contributed to the oversight, leaving the resident without a necessary care plan to guide catheter management.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in fall prevention and medication self-administration. One resident, at high risk for falls, lacked a care plan with fall prevention strategies, resulting in a fall and injury. Another resident, capable of self-administering medication, did not have their care plan updated to reflect this, despite evaluations and physician orders confirming their ability.
A resident with a history of urinary issues was found to have an incorrect Foley catheter size in place, contrary to the physician's order. The facility failed to ensure the correct catheter size was inserted or clarified, with staff confirming the discrepancy and a lack of documentation on catheter changes. Communication breakdown between hospice and facility staff contributed to the oversight.
The facility failed to monitor a resident's weight as prescribed, resulting in a 7% weight loss over six months, and did not administer the correct amount of water flushes via G-tube for another resident, leading to a 209 ml deficit over 72 hours. These deficiencies were acknowledged by the Registered Dietitian.
The facility failed to maintain essential kitchen equipment, affecting food safety. An inspection revealed stained steam table pans, a malfunctioning ice machine, and a freezer with non-functional thermometers. The temperature log showed inconsistent documentation, with recorded temperatures indicating improper storage. Facility policies required accurate thermometers and clean, working equipment.
A non-verbal resident with severe cognitive impairment was neglected by a CNA, who failed to check on the resident, leaving them in a wet brief for an extended period. The neglect was reported by another resident, leading to an investigation where multiple residents confirmed the allegations. The CNA was terminated following the investigation.
Failure to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The facility failed to follow physician orders for treatment of hypoglycemia for one resident with type 2 diabetes mellitus and unspecified diabetic retinopathy without macular edema. A review of the resident’s weights and vitals summary showed a blood sugar of 43 mg/dL on 10/29/2025, which was below the standing order threshold for treatment. The resident had an active order for Glucose Gel 15 grams by mouth as needed for blood sugar below 60 for conscious patients, but the Medication Administration Record did not show that Glucose Gel was given for the low blood sugar reading. During interviews, an LPN, the Unit Manager, the DON, and a Clinical Resource Nurse each confirmed that Glucose Gel was not administered for the blood sugar of 43 mg/dL. They also stated the blood sugar should have been rechecked within 15 minutes, documentation of a change in condition should have been completed, and the provider should have been notified. The facility’s standing orders for diabetic management, along with policies on administering medications and notifying the physician of changes in condition, were reviewed and reflected these requirements.
Pharmacist GDR Recommendation Not Acted Upon
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s recommendation for a gradual dose reduction (GDR) was acted upon for one sampled resident. Resident 30 was admitted and readmitted with diagnoses including phantom limb syndrome with pain, major depressive disorder recurrent moderate, and dementia unspecified severity with agitation. A physician order dated 10/18/2025 documented Fluoxetine HCl 40 mg by mouth daily for major depressive disorder recurrent moderate, and record review showed the resident had been receiving the same 40 mg dose since 08/18/2023. A Medication Regimen Review dated 09/29/2025 documented the consultant pharmacist’s recommendation to consider a trial dose reduction to Fluoxetine 20 mg daily. The Physician/Prescriber section showed the Agree box checked and the practitioner’s signature dated 10/24/2025, but the electronic medical record lacked evidence that the dose was reduced. Interviews with the Medical Records Coordinator and DON revealed the signed GDR form was sometimes routed inconsistently, and in this case it was filed in the medical record instead of being sent to the DON for review and processing. The consultant pharmacist stated the reduction was recommended because the resident had been receiving Fluoxetine 40 mg for over one year, and the DON stated new medical records staff were not fully clear on the process.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, resulting in a documented medication error rate of 6.67%. On 12/03/2025 at 7:40 AM, an LPN was observed preparing medications for a resident with diagnoses including GERD and essential hypertension and administered Aspirin 81 mg chewable, 1 tablet, and Losartan Potassium 50 mg, 1 tablet, by mouth. The resident’s physician orders dated 11/19/2025 and 11/22/2025 specified Aspirin Oral Capsule 81 mg, 1 tablet by mouth once daily for DVT, and Losartan Potassium 100 mg, 1 tablet by mouth one time a day for hypertension. At 7:50 AM, the LPN acknowledged the discrepancies and stated the physician orders should have been verified prior to administration. The facility policy titled Administering Medications, last revised April 2019, directed staff to verify the right medication and right dosage and to administer medications in accordance with prescriber orders.
Medication Handling and Legionella Water Management Deficiencies
Penalty
Summary
Safe and sanitary medication administration practices were not maintained for Resident 61, who was admitted with diagnoses including gastro-esophageal reflux disease (GERD). During a medication administration observation, an LPN retrieved a new bottle of aspirin for the resident and used a bare finger to remove a tablet from the container. The inspector directed the LPN to discard the tablet because it had been contaminated after being touched with a bare finger. While handling the medication, four aspirin tablets fell onto the medication cart surface, and the LPN returned those tablets to the original bottle instead of discarding them. Later that morning, the same LPN performed a blood glucose test on Resident 61. After completing the test, the LPN placed the used blood glucose meter into the scrub pocket without disinfecting the device. The LPN later acknowledged that the tablets that fell onto the medication cart were contaminated and should have been discarded, and that the blood glucose meter should have been disinfected after use and not stored in a pocket. The DON also acknowledged that the meter should have been disinfected before and after each use and that the LPN should not have handled aspirin tablets with bare hands. The facility’s Legionella Water Management Program was also found incomplete and not followed as written. The plan included a written narrative of water flow but did not include an illustrated flow diagram, had not been reviewed since July 2017, and lacked specific details for monitoring control measures such as hot water temperature ranges, locations for temperature checks, documentation methods, fixture inspection details, and inspection frequency. The plan also did not define specific corrective actions or what was meant by testing the water system or normal conditions, and the Maintenance Director stated there were no written records of water fixture inspections or water heater inspections, although the facility did flush seldom-used fixtures and adjust water temperatures without documenting those actions or results.
Failure to Administer Prescribed Tube Feeding
Penalty
Summary
The facility failed to ensure that tube feeding orders were followed and completely delivered for three residents, leading to potential nutritional deficits. Resident 54, who had a gastrostomy tube for nutrition due to conditions like dementia and dysphagia, was prescribed Glucerna 1.2 at 60 ml/hr with free water flushes. However, the enteral pump history revealed that the prescribed volume was not fully delivered over a 72-hour period, resulting in a shortage of 366 ml. This discrepancy was confirmed by a Registered Dietitian, who noted that the resident was supposed to receive 3,780 ml over 72 hours. Resident 48, diagnosed with dysphagia and dementia, was prescribed Jevity 1.5 at 55 ml/hr. The enteral pump history showed that only 3,062 ml was delivered over 72 hours, while 3,465 ml was intended. This discrepancy of 403 ml was confirmed by the Registered Dietitian, who indicated that the incomplete delivery could potentially lead to nutritional deficits over time. The resident had no significant weight change in the last 60 days, but the failure to administer the full dose was acknowledged by the Nurse Practitioner. Resident 11, with a gastrostomy tube due to dysphagia and dementia, was prescribed Glucerna 1.2 at 60 ml/hr for 24 hours. The enteral pump history revealed that only 3,666 ml was delivered over 72 hours, missing 654 ml of the prescribed formula. This discrepancy was confirmed by the Registered Dietitian, indicating a deficit of 750 calories. The failure to follow the prescribed enteral nutrition orders for these residents could have compromised their nutritional intake.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper labeling and dating of open food products and did not uphold sanitary conditions in the kitchen, which could potentially expose residents to foodborne illnesses. During an inspection, it was observed that the coffee machine and iced tea dispenser had visible coffee residue and appeared dirty. Two ovens were found to be heavily soiled with grease and burned food debris, and the kitchen manager acknowledged that the ovens should have been cleaned more frequently. Additionally, trays and a cart containing milk cartons were visibly soiled with dairy matter, and the kitchen floor, including areas under the steam table, stove, and dishwashing area, was covered with food debris and grease. The kitchen manager admitted that the kitchen was cleaned every two weeks, which was not sufficient. The inspection also revealed several issues with food products. A bag of lettuce dated over two weeks prior was found to be mushy and discolored, indicating it was no longer fresh. Several open food items, including non-dairy milk, shredded cheddar cheese, whole milk, reduced-fat lactose-free milk, and chopped garlic, were not labeled or dated. The kitchen manager confirmed these observations and stated that open food products should have been labeled and dated upon opening. The facility's policies on food storage and environmental cleanliness were not adhered to, as they required all foods to be labeled and dated and all food preparation areas to be maintained in a clean and sanitary condition.
Inadequate Infection Control Measures and PPE Usage
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place for residents requiring Enhanced Barrier Precautions (EBP). For one resident with a urinary catheter and an unstageable wound, there was no signage indicating EBP, nor was personal protective equipment (PPE) available. A hospice registered nurse provided care without a gown due to the absence of signage and available gowns, indicating unfamiliarity with the facility's protocol. Another resident with a stage 4 pressure ulcer had EBP signage, but staff did not wear gowns while providing incontinence care, and hand hygiene was not performed after glove removal. Additionally, the facility lacked a policy regarding the reuse of gowns after use. Staff were observed reusing cloth gowns throughout their shifts, which were designated for different staff members. The Infection Preventionist confirmed no policy was in place for reusing gowns after high-contact care activities, and the Director of Environmental Services indicated that sufficient washable gowns were available. The facility's existing policy on transmission-based precautions did not address the reuse of gowns, potentially leading to cross-contamination and the spread of infections.
Failure to Develop Baseline Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop a baseline care plan for the use of an indwelling Foley catheter within 48 hours of admission for a resident, identified as Resident 82. This resident was admitted with diagnoses including urinary tract infection, acute kidney infection, unstageable pressure ulcer, and urinary retention. Despite having a physician's order for a Foley catheter due to neurogenic bladder related to urine retention, no baseline care plan was formulated to address the catheter's use. Observations noted that the resident had a Foley catheter in place, but there was no care plan to guide its management, posing potential risks such as infection and inadequate monitoring. Interviews with facility staff, including an LPN and the Unit Manager, confirmed the absence of a care plan for the resident's Foley catheter. The Assistant Director of Nursing (ADON) explained that the Director of Nursing (DON) had restricted access to care plans, preferring to manage them personally, which contributed to the oversight. The ADON acknowledged that the resident, who was on hospice care, required a care plan to ensure adherence to person-centered care standards. Facility policies indicated that a baseline care plan should have been developed within 48 hours of admission to meet the resident's immediate needs, but this was not done for Resident 82.
Deficiencies in Care Planning for Fall Prevention and Medication Self-Administration
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in fall prevention and medication self-administration. Resident #56, who was admitted with severe sepsis, neurocognitive disorder, and other conditions, was identified as being at high risk for falls based on multiple assessments. Despite this, the care plan dated March 25, 2024, did not include any fall prevention strategies. This oversight was highlighted when the resident experienced a fall on August 10, 2024, resulting in a forehead laceration. A physician's order for a floor mattress was only obtained five days after the incident, indicating a delay in implementing necessary preventive measures. Resident #79, diagnosed with polyneuropathy and osteoarthritis, was evaluated and deemed capable of self-administering a garlic supplement. However, the resident's care plan was not updated to reflect this capability, despite a physician's order and evaluation confirming the resident's ability to self-administer the medication. The Assistant Director of Nursing acknowledged the oversight, noting that the care plan should have been revised to include this information. The facility's policy requires ongoing assessments and updates to care plans as residents' conditions change, which was not adhered to in these cases.
Failure to Follow Foley Catheter Order
Penalty
Summary
The facility failed to ensure that a resident's Foley catheter was properly assessed and the correct size was inserted or clarified. The resident, who had a history of urinary tract infection, acute kidney infection, unstageable pressure ulcer, and urinary retention, was admitted with a physician's order for a 16 French (Fr) Foley catheter with a 10 ml water balloon. However, observations revealed that the resident had an 18 Fr Foley catheter with a 5-10 ml water balloon in place, which was larger than the ordered size. This discrepancy was confirmed by both a Certified Nursing Assistant and a Licensed Practical Nurse, who acknowledged that the order should have been followed or clarified, and there was a lack of documentation regarding when the catheter was changed. The Unit Manager confirmed that the Foley catheter order had not been followed and suggested that the hospital might have changed the catheter size before the resident's return to the facility. Despite the resident being under hospice care, the facility was responsible for ensuring the order was followed or clarified. A communication breakdown between hospice and facility staff was identified, as hospice documentation should have been cross-checked with facility records. A hospice Registered Nurse confirmed that the resident was admitted to hospice with a Foley catheter inserted at the hospital and that the hospice admission nurse documented a 16 Fr catheter but may have missed checking the actual catheter in place. The facility's policy on catheter care emphasized the importance of reviewing the resident's care plan to prevent catheter-associated urinary tract infections.
Failure to Monitor Weight and Administer Prescribed Hydration
Penalty
Summary
The facility failed to adequately monitor the weight of a resident who was prescribed weight gain. The resident, who had multiple diagnoses including anxiety, acute psychosis, and dysphagia, experienced a 7% weight loss over six months. The facility's records showed that the resident's weight was only recorded three times in 120 days, contrary to the facility's policy which required weekly weight monitoring for residents with prescribed weight gain. The Registered Dietitian acknowledged that the resident's weight was not monitored as per policy due to the resident's refusal to be weighed, and this refusal was not documented in the medical record or care plan. Additionally, the facility did not ensure that a resident receiving hydration via a gastrostomy tube received the prescribed amount of water flushes. The resident, who had diagnoses including dysphagia and dementia, was ordered to receive 30 ml/hr of water flushes via the G-tube. However, a review of the enteral pump's memory history revealed a discrepancy, with the resident receiving 209 ml less than the prescribed amount over 72 hours. The Registered Dietitian confirmed that the water flush order was not followed, impacting the resident's daily water requirements.
Deficient Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in good repair, which could potentially affect the quality and safety of food storage and production. During an inspection, six steam table pans were found with significant staining and build-up, indicating possible water damage and inadequate cleaning practices. Additionally, the ice machine had significant white mineral deposits on both its exterior and interior surfaces, and the kitchen manager reported ongoing performance issues with the machine despite previous repairs. Furthermore, a freezer was found with its manufacturer's thermometer out of service, and the internal thermometer was not functioning. The kitchen manager confirmed this and stated that the thermometer was under repair. Despite this, staff were manually checking the meal products to ensure they were hard frozen. The temperature log showed inconsistent documentation, with recorded temperatures indicating the freezer was not maintaining appropriate storage temperatures. The facility's policies required accurate thermometers in each refrigerator and freezer, with daily temperature records, and all foodservice equipment to be clean, sanitary, and in proper working order.
Neglect of Non-Verbal Resident by CNA
Penalty
Summary
The facility failed to protect a dependent, non-verbal resident from neglect, as evidenced by the resident being left in a wet brief for an extended period. The resident, who had severe cognitive impairment and multiple diagnoses including intellectual disabilities and dementia, was admitted and readmitted to the facility on unspecified dates. A report of neglect was made to the state agency, and the Assistant Administrator confirmed the concern regarding neglect by a Certified Nursing Assistant (CNA). The neglect was initially reported by another resident to the social worker, who followed protocol by contacting the abuse coordinator, leading to an investigation. The investigation, led by the Assistant Administrator and the Director of Nursing (DON), involved interviews with five residents, three of whom confirmed the neglect allegations. The employee in question was interviewed and subsequently terminated for neglect, with the incident reported to the appropriate licensing board. The DON explained that the facility's expectation was for staff to make rounds at least every two hours, but the employee failed to respond to call lights or check on residents during their shift, leading to the neglect of multiple residents.
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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 Boulder City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boulder City Hospital Snf | 0.6 mi | ★★★★★ | 0 | 0 |
| Nevada State Veterans Home - Boulder City | 2.2 mi | ★★★★★ | 13 | 0 |
| Henderson Health And Rehabilitation | 9.7 mi | ★★★★★ | 2 | 0 |
| Tlc Care Center | 13.7 mi | ★★★★★ | 6 | 0 |
| Oasis Nursing & Rehab Of Green Valley | 15.7 mi | ★★★★★ | 20 | 0 |
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