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 Mountainview Nursing Home during CMS and state inspections, most recent first.
A resident with dementia and a history of falls exited the facility unsupervised during the night, after staff failed to respond appropriately to door and bed alarms. The resident was later found outside in cold weather, hypothermic, and with a subdural hematoma, despite being identified as high risk for wandering and falls in her care plan.
The facility failed to follow infection control guidelines during medication administration for two residents with feeding tubes, as staff did not use appropriate PPE. Additionally, a CNA improperly exited a COVID-19 positive resident's room without removing PPE, and an LPN did not adhere to proper procedures during a dressing change for a resident with a sacral ulcer.
Two residents were involved in a physical and verbal altercation in the common area, where one resident took a TV remote from another, leading to a confrontation. The situation escalated when one resident physically assaulted the other, who retaliated using a powerchair. Staff intervened, and no injuries were reported. The facility's policy on abuse prevention was not effectively implemented, as the incident occurred despite existing measures.
A facility failed to provide a written baseline care plan to a resident and/or their responsible party within 48 hours of admission. The resident, admitted with multiple diagnoses, did not have a signed Acknowledgement of Receipt Admission Baseline Care Plan form. Interviews revealed that the family member was not contacted about the care plan, and the Social Services Director admitted to the oversight.
The facility failed to develop comprehensive care plans for two residents, one with medication and meal refusals and another with a pressure ulcer. Despite documentation of these issues, the care plans were not updated to address them. Interviews with staff confirmed the oversight, leading to unmet care needs.
A resident's care plan was not updated to reflect a DNR order, despite the resident's daughter signing the directive upon admission. The care plan incorrectly indicated a Full Code status, leading to potential unmet care needs. Interviews revealed that the MDS nurse did not review orders when updating the care plan, and care plan conference summaries were improperly stored.
A facility failed to ensure proper communication with a dialysis center for a resident with end-stage renal disease. The resident's Dialysis Communication Record lacked documentation on several occasions, including details about the shunt site, lab values, medications, and food/fluid intake. The DON acknowledged that the nurse should have contacted the dialysis center to complete the records and document the information in the progress notes.
A facility failed to explain the risks and benefits of psychotropic medications to a resident and/or their representative and did not adequately monitor behaviors and side effects. The resident, with anxiety and major depressive disorder, was on multiple psychotropic medications without documented consent for some. Staff interviews revealed incomplete behavior documentation and a lack of specific monitoring for medication-related behaviors and side effects.
A potential medication error occurred when an LPN prepared to administer insulin from a pen labeled for another resident. The error was identified by a surveyor before administration, highlighting a failure to follow the facility's policy of verifying medication labels three times. Interviews confirmed the expectation for nurses to ensure correct patient, dosage, route, and frequency.
The facility failed to properly store Lorazepam, a controlled medication, in permanently affixed compartments in medication refrigerators on two units. Observations revealed that transparent plastic containers with locks, containing Lorazepam for three residents, were not permanently affixed as required by facility policy. Staff interviews indicated a lack of awareness about this requirement.
Failure to Prevent Resident Elopement and Respond to Alarms
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and dementia, who had a history of repeated falls and unsteadiness, was found outside the facility lying on the ground in cold weather, dressed only in pajamas and slippers. The resident was admitted with diagnoses that included cognitive impairment and required supervision or assistance with walking, as well as the use of a bed alarm for safety. Despite these precautions, the resident was able to exit the facility without her walker or code alert sensor, and staff did not respond appropriately to alarms that were activated during the night. Staff interviews and record reviews revealed that alarms sounded during the early morning hours, but staff either misidentified the alarms or failed to investigate them properly. One staff member reported hearing an alarm around 4:00 AM but did not go outside to check, and the alarm was turned off without confirming the resident's whereabouts. Another staff member indicated that the door alarm was mistaken for a fire alarm and was silenced without further action. The resident was not accounted for until she was found outside by staff during morning rounds, at which point emergency services were called. The resident was subsequently transported to the hospital, where she was found to be hypothermic and diagnosed with an acute right subdural hematoma with midline shift, as well as multiple scalp hematomas and ecchymoses. The incident was further compounded by the fact that the resident's care plan identified her as at risk for wandering and safety concerns, and staff had been informed of her high fall risk and wandering behaviors. The failure to provide adequate supervision and to respond appropriately to alarms directly led to the resident's elopement and subsequent injury.
Removal Plan
- In-Service on Falls and Causes completed.
- In-Service on Safety and Supervision completed.
- Abuse and Neglect In-Service Training completed.
- Change in Resident Condition/Accidents and Incidents (Steps to Compliance) completed.
- Elopement In-Service and Training completed.
- In-Service and Training in reference to responding to Door Alarms completed.
- Door Alarm In-Service and Training conducted by Maintenance Director completed.
- In-Service on Choke Alarm completed by Maintenance Director.
- Fire Drill In-Service Training completed.
- Designee/Associate Administrator will educate ALL staff on Falls and Causes; Safety and Supervision of Residents; Abuse and Neglect; Change in Resident Condition; Elopement; Responding to Door Alarms; Door Alarms Checks (Maintenance), Choke Alarm, and Fire Drills.
- All employees will be educated on correct policies and procedures during orientation.
- Designee/Associate Administrator will complete an audit of in-services and training for Falls and Causes with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Safety and Supervision with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Abuse and Neglect with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Change in Resident Condition with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Elopement with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Responding to Door Alarms with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Door Alarm Checks with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Choke Alarms with results reported to the QAPI committee.
- Designee/Associate Administrator will complete an audit of in-services and training for Fire Drills with results reported to the QAPI committee.
Infection Control Deficiencies in Medication Administration and PPE Use
Penalty
Summary
The facility failed to adhere to infection control guidelines during medication administration for two residents with feeding tubes. One LPN was observed touching the inside of a medicine cup and handling pills with bare hands before administering them through a gastrostomy tube. The LPN only wore gloves during the procedure, and there was no order for Enhanced Barrier Precautions for the resident. Another RN also wore only gloves while administering medications via a feeding tube to a different resident, despite acknowledging the need for a gown, gloves, and mask under Enhanced Barrier Precautions. In another instance, a CNA failed to properly follow PPE protocols for a COVID-19 positive resident. The CNA donned an N95 mask, gloves, and a gown before entering the resident's room but exited into the hallway without removing the PPE, which was against the facility's infection control policy. The CNA admitted to forgetting to remove the PPE before leaving the room, which could potentially spread infection. Additionally, during a dressing change for a resident with a sacral ulcer, an LPN did not wait for the appropriate dry time after cleaning the overbed table with a disinfectant wipe before placing a barrier. The LPN also improperly wiped bowel movement towards the wound, contrary to infection control practices. The DON confirmed that the nurse should have waited for the dry time and should not have wiped germs toward the wound.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident physical and verbal abuse. The incident involved two residents, R18 and R85, who were in the common area when R85 took a TV remote from another resident. R18 verbally confronted R85 about his actions, leading to a verbal exchange where R85 used derogatory language. The situation escalated when R85 physically assaulted R18 by punching him, and R18 retaliated by using his powerchair to push R85. Staff intervened, and R18 called 911, but no injuries were noted, and no charges were filed. The facility's policy on abuse and neglect management was not effectively implemented, as evidenced by the altercation between R18 and R85. The policy states that residents have the right to be free from abuse and that the facility is committed to preventing abuse through various systems and training. However, the incident indicates a failure in preventing resident-to-resident abuse, as staff intervention occurred only after the altercation had escalated. Interviews with staff and residents confirmed the occurrence of the incident, and the facility reported it to the state survey agency.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a written copy of the baseline care plan to a resident and/or their responsible party within 48 hours of admission, as required. The resident, identified as R261, was admitted with diagnoses including epilepsy, anoxic brain damage, diabetes mellitus, and chronic pain. A review of the resident's medical records revealed that the Acknowledgement of Receipt Admission Baseline Care Plan form, dated 10/24/24, lacked the signature of the resident or their responsible party. Interviews conducted with the family member and facility staff confirmed that the family member had not been contacted regarding the care plan, and the Social Services Director acknowledged the oversight in obtaining the necessary signature.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to unmet care needs. One resident, who was admitted with diagnoses including atrial fibrillation, hypertension, and congestive heart failure, frequently refused medications and meals. Despite documentation of these refusals in the resident's progress notes and medication administration record, the care plan did not address these issues. Interviews with facility staff, including an LPN and the DON, confirmed that the care plan should have included strategies for managing the resident's refusals, but it did not. Another resident, who was cognitively intact, had a pressure ulcer on the sacral area that was not included in the care plan. A telephone order documented the presence of the wound and specified treatment instructions, but the care plan was not updated to reflect this new condition. The DON was unaware of the pressure injury until it was confirmed by the wound nurse, and the MDS Coordinator acknowledged that the care plan was not updated when the wound was identified. This oversight resulted in a lack of documented care planning for the resident's pressure ulcer.
Failure to Update Resident's Care Plan with Correct Advanced Directive
Penalty
Summary
The facility failed to update the care plan of a resident, identified as R92, to reflect an updated advanced directive status. R92 was admitted with diagnoses including stroke, congestive heart failure, and major depressive disorder. The resident's care plan, dated after the admission, incorrectly stated that the resident wanted all possible interventions in an emergency, including CPR, despite a DNR order signed by the resident's daughter upon admission. The care plan conference summary also incorrectly documented the resident as a Full Code. Interviews with facility staff revealed a lack of communication and coordination in updating the care plan. The Director of Nursing and the MDS Coordinator indicated that the MDS nurse is responsible for updating care plans with each MDS assessment, incorporating new orders and interventions. However, the MDS Coordinator admitted uncertainty about reviewing the orders when updating the care plan. Additionally, the Licensed Practical Nurse noted that the care plan was not updated with new orders as required. The Director of Nursing acknowledged that care plan conference summaries were improperly kept in the MDS office instead of being filed in the medical record.
Lack of Communication with Dialysis Center for Resident Care
Penalty
Summary
The facility failed to ensure proper collaboration of care with the dialysis center for a resident requiring dialysis services. The resident, who was admitted with diagnoses including cerebrovascular accident, end-stage renal disease, and chronic kidney disease stage five, was receiving dialysis services as indicated in their medical records. However, the Dialysis Communication Record for the resident was found to have missing documentation from the dialysis center on several occasions. This included missing information about the shunt site, lab values, medications administered during dialysis, recommendations, food/fluid intake, and missing signatures and dates. During an interview, the Director of Nursing and the Assistant Administrator were informed of these missing components in the resident's medical record. The Director of Nursing acknowledged that the nurse responsible for receiving the communication from the dialysis center should have contacted the center to obtain a complete report or faxed the sheet back to have it completed. The nurse was also expected to document this information in the progress notes, which was not done, leading to a lack of communication between the facility and the dialysis center.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the risks and benefits of psychotropic medications were explained to a resident and/or their representative before use, and did not adequately monitor targeted behaviors and side effects for a resident receiving these medications. The resident, who was admitted with diagnoses of anxiety and major depressive disorder, was receiving multiple psychotropic medications, including Effexor ER, Risperidone, Trazodone, and Klonopin. However, there was no documented consent for Effexor ER, Klonopin, and Trazodone, and the facility's behavior documentation was incomplete or missing, failing to specify behaviors or side effects related to the medications. Interviews with facility staff revealed a lack of specific knowledge about the behaviors each medication was intended to address and the side effects to monitor. The LPN and DON both indicated that while behaviors were documented, they were not linked to specific medications, and the behavior monitoring sheets were not consistently completed. This lack of documentation and monitoring had the potential to lead to excessive administration of psychotropic medications and hindered the ability of the resident and/or their representative to make informed decisions regarding their use.
Insulin Pen Mislabeling Leads to Potential Medication Error
Penalty
Summary
The facility failed to accurately verify the insulin pen being used for a resident, leading to a potential medication error. During a medication administration observation, a surveyor noted that the insulin pen labeled for another resident was about to be used on Resident 14. The insulin pen, labeled for Resident 101, was prepared for administration to Resident 14 without proper verification of the resident's name on the pen. This oversight was identified by the surveyor before the insulin was administered, preventing the potential error. The facility's policy requires the individual administering medication to check the label three times to ensure the right medication, dosage, time, and method of administration. However, this protocol was not followed by LPN8, who initially insisted that the insulin was for Resident 14. The error was acknowledged after the surveyor intervened, and LPN8 returned the insulin pen to the medication cart. Interviews with LPN5 and the Director of Nursing confirmed the expectation that nurses verify the correct patient, dosage, route, and frequency before administering medication.
Deficiency in Controlled Medication Storage
Penalty
Summary
The facility failed to comply with regulations regarding the storage of controlled medications, specifically Lorazepam, on two of its units. During observations, it was found that the medication refrigerators on the North and [NAME] Units contained transparent plastic containers with two locks, which were not permanently affixed to the refrigerators. These containers held Lorazepam, a Schedule II-V controlled medication, for three residents: R259, R2, and R11. The facility's policy requires that such medications be stored in separately locked, permanently affixed compartments, which was not adhered to in this case. Interviews with staff, including LPNs and the Director of Nursing, revealed a lack of awareness regarding the requirement for the containers to be permanently affixed. LPN9 confirmed that the container with Lorazepam for R259 could be removed from the refrigerator, and LPN3 confirmed the same for the containers holding Lorazepam for R2 and R11. The Director of Nursing was unaware of the necessity for the containers to be permanently affixed, indicating a gap in policy implementation and staff training regarding medication storage requirements.
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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.
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Illustrative
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Nursing homes near Spartanburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Oak At North Grove Inc | 3.8 mi | ★★★★★ | 1 | 0 |
| White Oak Estates | 4.3 mi | ★★★★★ | 2 | 0 |
| White Oak Manor - Spartanburg | 4.8 mi | ★★★★★ | 4 | 0 |
| Magnolia Manor - Spartanburg | 4.9 mi | ★★★★★ | 0 | 0 |
| Spartanburg Hospital For Restorative Care Snf | 4.9 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.