Mountain View Skilled Nursing: Report Failure - WY

The harassment escalated to violence on September 19 when the two residents fought after returning from a nature ride. Federal inspectors found the non-verbal resident developed a black eye and red marks on the head, while the antagonistic resident suffered scratches on the chin.

Staff witnessed the confrontation unfold near the Sunflower unit. CNA #1 heard another staff member yell "stop it" and turned to see both residents "swinging at each other." The fight ended with visible injuries on both residents.

The non-verbal resident, identified as resident #3, had become fearful following the incident. When asked if they were okay afterward, resident #3 shook their head no and pointed to their arm and head where injuries were visible.

Six days later, another violent confrontation erupted.

Resident #1 woke up upset on September 25 and began "calling people derogatory names," according to CNA #3. When staff denied a phone call request, resident #1 became enraged and chased after the nursing assistant.

The CNA called security as resident #2, who had been staying in their room to avoid conflict, emerged after hearing the commotion. Resident #2 grabbed water and headed toward resident #1's room.

By the time staff arrived, resident #1 was "soaked" and the two residents were in a physical fight. Resident #2 was "trying to punch resident #1" while resident #1 struck back "on top of the head with a television remote."

Even after staff separated them, resident #2 remained "angry and was yelling at resident #1."

The pattern of harassment extended beyond physical violence. CNA #2 witnessed resident #1 call resident #3 "a retard" on multiple occasions. When staff told resident #1 to stop making such statements, "resident #1 would increase the statements."

During one incident when resident #3 came to visit CNA #3, resident #1 said: "When you are done playing with the retard, I need a napkin."

On another occasion, resident #1 stated: "Oh my god, you guys play with [him/her] like [s/he] is a fucking 3-year-old" in reference to resident #3.

The harassment created a climate of fear throughout the facility. Resident #3 "indicated s/he was afraid of resident #1" and when they previously shared living quarters, resident #3 "would remain in his/her room to avoid resident #1."

Resident #2 also modified behavior to avoid confrontation, often staying in their room to avoid resident #1. CNA #3 described resident #2 as "protective of staff and other residents" who intervened because "resident #1 antagonized other residents and staff."

RN #1 confirmed the pattern, telling inspectors that resident #3 "got along with everyone except resident #1 because s/he called resident #3 retarded." The nurse noted that resident #1 "had other incidents with individuals due to derogatory statements."

Staff struggled with ineffective interventions. CNA #3 explained that when staff attempted to redirect resident #1's behavior, "it was not always effective." The verbal abuse continued despite repeated attempts to stop it.

The September 19 altercation began when resident #1 was walking toward the Sunflower unit "as that was where his friends lived." Words were exchanged between resident #1 and the non-verbal resident #3, who then "hit resident #1 in the head and ran his/her wheelchair into resident #1."

Resident #1 retaliated, hitting resident #3 and claiming a "right to defend him/herself." Both residents required assessment and treatment for their injuries.

The incident report showed both residents sustained "minor injuries that were treated by the facility," but the impact extended beyond physical harm. The non-verbal resident's black eye served as a visible reminder of the facility's failure to protect vulnerable residents from harassment and assault.

CNA #1 observed that resident #1 claimed resident #3 "had pushed him/her off the sidewalk and hit him/her," suggesting the antagonistic resident viewed themselves as the victim despite the pattern of verbal abuse that preceded the violence.

The facility's policy titled "Prevention of Resident Abuse, Neglect, and Exploitation" dated May 14, 2025, states it is "the policy and practice of the WLRC that all residents will be protected from abuse and neglect."

Yet staff interviews revealed a systematic failure to protect residents from ongoing harassment. The non-verbal resident remained afraid, other residents modified their behavior to avoid confrontation, and the verbal abuse continued despite staff awareness of the problem.

Federal inspectors determined the facility failed to ensure residents were free from abuse and neglect, citing actual harm to few residents. The inspection was conducted in response to a complaint filed with regulators.

The case illustrates how verbal harassment can escalate to physical violence in nursing home settings, particularly when staff lack effective tools to address persistent behavioral problems. Resident #3 continues to live in an environment where they face both the memory of physical assault and the ongoing threat of verbal abuse from someone they cannot avoid.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Mountain View Skilled Nursing Community At Wlrc from 2025-10-15 including all violations, facility responses, and corrective action plans.

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