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 Skilled Nursing Community At Wlrc during CMS and state inspections, most recent first.
Failure to Protect Residents from Abuse and Neglect: A resident with normal cognition struck another resident with a cup after an argument, causing a forehead mark. In another incident, a resident with severe cognitive impairment made sexually explicit statements, exposed genitals, and urinated in a common area, upsetting another resident. A third resident was found saturated in urine and feces with feces throughout the room, and required extensive cleaning after missed checks and delayed care.
A resident with severe cognitive impairment and a documented high choking risk was left unsupervised at the dining table after a meal, where the resident obtained pizza from another resident and choked, requiring Heimlich thrusts, suctioning, increased O2, and ER transfer. Another resident with dementia and wandering/elopement risk had repeated unsupervised exits from the residence, including being found outside on multiple occasions, with 15 elopement incidents documented and no evidence that elopement was discussed at care conferences.
A resident with moderate cognitive impairment, schizoaffective disorder, and a history of medication refusal received Invega injections in ways that did not follow standard IM administration. Records and an investigation showed the DON administered an injection through clothing during an outing after the resident had refused medication earlier, using distraction items and clinical judgment because of the resident's aggression history. Another note documented a monthly Invega injection given after transfer from a van, with no visible discomfort noted.
Two residents experienced physical harm after repeated altercations involving physical aggression and verbal provocations, including derogatory name-calling and accusations, with staff unable to consistently prevent or de-escalate these incidents. Injuries such as abrasions, swelling, and bruising were documented, and staff interviews confirmed ongoing difficulties in managing the behaviors of those involved.
A resident with multiple behavioral health diagnoses repeatedly engaged in verbally and physically aggressive behavior toward others, leading to several altercations and minor injuries. Staff interventions, primarily verbal redirection, were inconsistently effective, and staff expressed uncertainty about managing the resident's behaviors. The facility did not provide necessary behavioral health care and services, resulting in actual harm.
Two residents were involved in a verbal and physical altercation, but the incident was not reported to the state survey agency within the required timeframe due to lack of staff access to the reporting system on weekends, contrary to facility policy.
A resident was transferred to the hospital due to an acute change of condition, but the facility failed to provide a written transfer notice to the resident or their representative. The social services director confirmed the absence of the notice, which is required by the facility's policy for emergency transfers.
The facility failed to provide a resident with written information on the bed-hold policy during a hospital transfer for an acute condition. The social services director confirmed the absence of the bed-hold notice, despite the facility's policy requiring such information to be given upon admission and before any transfer.
The facility failed to provide a required annual comprehensive psychiatric evaluation for a resident with serious mental illness and severe cognitive impairment, as identified in the PASARR Level II assessment. The resident's last psychiatric evaluation was completed over two years ago, and the social services director confirmed the deficiency.
A facility failed to offer a pneumococcal vaccine to a resident as per CDC recommendations. The resident's MDS assessment indicated the vaccine was not up-to-date, and there was no record of prior vaccination. The DON confirmed the vaccine was not offered, despite facility policy requiring all residents to be offered vaccines unless contraindicated or previously vaccinated.
The facility did not conduct an annual review of its IPCP policies, including the Antibiotic Stewardship, Written Exposure Control Plan & Health Outbreak Guidelines, and Vaccination of Residents policies. An interview with the DON confirmed the lack of required annual reviews, affecting a census of 13 residents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from verbal abuse, physical abuse, and sexual abuse involving staff and other residents for 3 of 8 sampled residents. Resident #4 had a BIMS score of 15/15 with diagnoses including non-traumatic brain dysfunction, anxiety, and schizophrenia. Resident #16 had a BIMS score of 12/15 with diagnoses including traumatic brain dysfunction, anxiety, and depression. The incident report showed that resident #16 and resident #4 had an altercation in the kitchen area after words were exchanged, and resident #4 struck resident #16 in the forehead with a cup. Staff intervened, both residents were separated and assessed, and RN #5 later observed a bruise on resident #4’s back and a half-circle mark on resident #16’s forehead consistent with the cup. Resident #6 had a BIMS score of 4/15 with severe cognitive impairment and diagnoses including traumatic brain injury, Parkinson’s disease, psychotic disorder, and PTSD. A facility investigation showed resident #6 made sexually explicit statements toward staff and resident #4, exposed genitals, made inappropriate sexual gestures, asked others to touch the genitals, and urinated on the carpet in a common area. A code green was called, and resident #4 was removed from the area. RN #7 stated resident #6 had demonstrated threatening behaviors that were redirected until the resident exposed themselves, made sexual gestures, and urinated on the floor, which upset resident #4 and required redirection. Resident #12 had a BIMS score of 11/15 with diagnoses including intracranial injury, neurogenic bladder, bowel and bladder incontinence, and hemiplegia. The investigation showed resident #12 was found in clothes from the prior day, saturated in urine and feces, with feces on the walls, floor, oxygen machine, and TV. The report also noted resident #12’s life safety checks were not performed every 30 minutes, and CNA #17 and CNA #19 were placed on administrative leave and later terminated. Staff interviews confirmed the resident had been yelling for help, had feces throughout the room and on the resident, and required extensive cleaning because the feces had dried on.
Failure to Supervise Resident During Meals and Wandering/Elopement Events
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with severe cognitive impairment and a documented high to severe choking and aspiration risk. The resident had diagnoses including traumatic brain injury, non-Alzheimer’s dementia, hemiplegia, and chronic lung disease, and the care plan required 1:1 supervision during all meals, close attention to swallowing, a pureed diet, and thickened liquids. The care plan also stated the resident should not be left around food unsupervised to prevent and reduce the risk of choking. During a meal, the resident was left at the dining room table after finishing eating while other residents continued to eat. The CNA assigned to supervise the resident left the dining area with another CNA and went to the staff room, and a third CNA was on break. When staff returned, they found the resident with a slice of pizza. One CNA removed the pizza from the resident’s hands and mouth and then left the building for a break. After that, another CNA and the first CNA observed the resident choking on remaining pizza and called for help. Nursing staff responded with Heimlich maneuver thrusts and suctioning, and the resident developed below normal oxygen levels, required increased supplemental oxygen, and was sent to the ER for evaluation. The facility also failed to adequately supervise a resident with severe cognitive impairment, wandering behaviors, and repeated elopement incidents. The resident’s record showed wandering behaviors during quarterly assessments, an elopement risk assessment indicating weekly attempted elopement with some successful attempts, and a care plan calling for staff vigilance, STOP signage, door alarms, wander guard use, and daily reminders. Despite this, the resident was found outside the residence on multiple occasions, including attempting to enter an adjacent cottage at night and later being found outside the front door area and then missing until located by security. The record documented 15 elopement incidents over the review period, and care conference notes showed no evidence that elopement had been discussed or interventions evaluated.
Improper Administration of Invega Injection
Penalty
Summary
The facility failed to ensure resident #10 received treatment and care in accordance with professional standards of practice for Invega Sustenna injections. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and diagnoses that included nontraumatic brain dysfunction, schizoaffective disorder, depression, and hypertension. The care plan noted a history of delirium, cognitive loss, depression, and non-compliance with medications, and stated staff were to approach the resident calmly about medications and accept refusals if given. The record showed one monthly Invega injection was administered after the resident was transferred to a wheelchair from a van, with the medication given to the left flank area and the resident showing no visible discomfort. A facility investigation also described an incident in which the DON administered an Invega injection through the resident's clothing during an outing after the resident had refused the medication earlier. The investigation stated sensory distraction items were used and that the injection was given to the left deltoid through clothing using nursing clinical judgment because of the resident's history of aggression and inability to safely expose the injection site. The DON later stated the resident had received recent Invega injections with the guardian's informed consent, while social services reported concern that the resident had been taken off campus to receive a shot after refusing it that morning.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in actual physical harm to two residents. Multiple incidents were documented in which one resident, who had diagnoses including schizophrenia and bipolar disorder and was cognitively intact, engaged in physical altercations with another resident. These altercations were often triggered by verbal provocations, including derogatory name-calling and accusations of theft. The aggressive behaviors included throwing objects, physical fighting, and attempts to punch, kick, or otherwise harm another resident. In several instances, staff had to intervene to separate the residents, and minor injuries such as abrasions and swelling were noted. Another resident, who had cerebral palsy, seizure disorder, and anxiety disorder, and used a motorized wheelchair, was also involved in a physical altercation with a peer. This resident, described as non-verbal and generally getting along with others except for one individual, was observed hitting and being hit by another resident after an exchange of words. The altercation resulted in visible injuries, including swelling and bruising to the eye and a small scrape. Staff and witnesses reported that the instigating resident had a history of taunting and using derogatory language toward others, which contributed to the escalation of these incidents. Interviews with staff confirmed that the resident who frequently used derogatory language was known to antagonize others and that redirection efforts by staff were not always effective. Staff also reported that some residents would attempt to avoid the instigating resident by staying in their rooms, and that fear and distress were present among those targeted. Despite the facility's policy stating that all residents would be protected from abuse and neglect, the documented incidents demonstrate that the facility did not effectively prevent or intervene in resident-to-resident abuse, resulting in physical harm and emotional distress.
Failure to Provide Effective Behavioral Health Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with multiple diagnoses, including non-Alzheimer's dementia, traumatic brain injury, anxiety disorder, depression, and psychotic disorder. The resident was cognitively intact but exhibited frequent verbal and physical behavioral symptoms directed at both staff and other residents. The care plan included interventions such as redirection, support to ignore provocations, and escalation to nursing or provider involvement if needed. However, staff interviews and incident reports revealed that these interventions were inconsistently implemented and often ineffective in managing the resident's behaviors. Multiple documented incidents occurred in which the resident engaged in verbally abusive and derogatory behavior toward other residents, leading to physical altercations. These included name-calling, threats, and provoking other residents, which resulted in several physical confrontations, some causing minor injuries such as abrasions and scratches. Staff consistently reported that their primary intervention was to tell the resident to stop, which was not reliably effective. In several cases, the resident's behavior escalated to the point where other residents retaliated physically, and staff were unable to de-escalate the situation or prevent harm. Interviews with CNAs and an RN indicated a lack of effective behavioral health interventions and uncertainty among staff regarding how to manage the resident's behaviors. Staff described the resident as persistently agitating others and noted that redirection and verbal prompts were insufficient. The repeated incidents and staff accounts demonstrate that the facility did not ensure the resident received the necessary behavioral health care and services to maintain the highest practicable physical, mental, and psychosocial well-being, resulting in actual harm.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse involving two residents. An incident occurred in which one resident verbally insulted another, who then retaliated by throwing a cup of juice. The incident was documented in a facility report on the day it occurred, but was not reported to the state survey agency until three days later. Staff interviews confirmed that the delay was due to the absence of personnel with access to the incident database during weekends. Facility policy requires that such incidents be reported to the appropriate authorities within specific timeframes, which was not followed in this case.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was transferred to the hospital due to an acute change of condition. A review of the nurse progress note dated 12/16/24 indicated that the resident was transferred, but there was no evidence of a written transfer notice being issued to the resident or their representative. An interview with the social services director on 1/24/25 confirmed the inability to locate the transfer notice. The facility's policy, dated 10/28/24, requires that when a resident is transferred on an emergency basis, verbal confirmation of the transfer should be provided immediately or as soon as practicable, followed by a written notice. However, this procedure was not followed in this instance.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
The facility failed to provide written information on the bed-hold policy for a resident who was transferred to the hospital due to an acute change of condition. A review of the nurse progress note dated 12/16/24 indicated that the resident was transferred, but there was no evidence that the facility issued the required written information on the bed-hold policy to the resident or their representative at the time of hospitalization. An interview with the social services director on 1/24/25 confirmed that the bed-hold notice could not be located. The facility's Bed Hold and Return policy, reviewed on 9/24/24, mandates that residents and/or their representatives be provided with written information regarding bed-hold policies upon admission and prior to any transfer.
Failure to Provide Required Psychiatric Evaluation for Resident
Penalty
Summary
The facility failed to arrange for specialized services to meet the needs of a resident as identified in the Preadmission Screening and Resident Review (PASARR) Level II assessment. The resident, who was admitted from an inpatient psychiatric hospital, was determined to have a serious mental illness and severe cognitive impairment, with a BIMS score of 3 out of 15. Diagnoses included anxiety disorder, depression, bipolar disorder, and psychotic disorder. The PASARR Level II Determination Summary Report recommended a minimum of an annual comprehensive psychiatric evaluation to clarify the current psychiatric diagnosis and appropriate treatment plan. However, the resident's medical record showed that the last psychiatric evaluation was completed on 2/1/21, and an interview with the social services director confirmed that an annual comprehensive psychiatric evaluation had not been completed as required.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered pneumococcal immunizations in accordance with CDC recommendations. A review of the quarterly MDS assessment for a resident admitted to the facility revealed that the resident's pneumococcal vaccine was not up-to-date and had not been offered. The resident's medical record showed no evidence of prior vaccination. An interview with the Director of Nursing confirmed that the resident had not been offered the vaccine. The facility's policy stated that all residents should be offered vaccines unless medically contraindicated or previously vaccinated. The CDC recommends pneumococcal vaccination for all adults who have never received a pneumococcal conjugate vaccine and are of a certain age.
Failure to Conduct Annual Review of IPCP Policies
Penalty
Summary
The facility failed to conduct an annual review of its Infection Prevention and Control Program (IPCP), as required. The review of the facility's IPCP policies revealed several concerns: the Antibiotic Stewardship policy, approved on March 11, 2022, the Written Exposure Control Plan & Health Outbreak Guidelines policy, approved on April 5, 2022, and the Vaccination of Residents policy, also approved on April 5, 2022, all showed no evidence of subsequent review. Additionally, the Infection Prevention and Control policy, approved on May 18, 2023, also lacked evidence of a subsequent review. An interview with the Director of Nursing (DON) confirmed that the IPCP policies had not been reviewed annually, as required by regulations. The facility's census at the time was 13, indicating the number of residents potentially affected by this oversight.
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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 Lander
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westward Heights Care Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Morning Star Care Center | 13.5 mi | ★★★★★ | 0 | 0 |
| Wind River Rehabilitation And Wellness | 22.1 mi | ★★★★★ | 4 | 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.