Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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 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 | — | 0 | 0 |
| Morning Star Care Center | 13.5 mi | — | 0 | 0 |
| Wind River Rehabilitation And Wellness | 22.1 mi | — | 2 | 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 August 2026) and official state health department websites.