Mountain View Skilled Nursing: Abuse Violations - WY

The September incidents left the victim so fearful that the resident would shake their head "no" when asked if they were okay and point to injuries on their arm and head, according to a federal inspection completed October 15.

Federal inspectors found the facility failed to protect residents from abuse, documenting multiple physical altercations and a pattern of derogatory verbal attacks that staff witnessed but couldn't stop.

The violence peaked on September 19 during what was supposed to be a therapeutic nature ride. After resident #1 was helped off the bus, a certified nursing assistant heard another staff member yell "stop it." When the CNA turned around, he observed residents #1 and #3 "swinging at each other" and hitting each other.

Resident #1 sustained a scratch on the chin. Resident #3, who is non-verbal, had a red area on the head and eye that turned into a black eye the following day.

The altercation began when resident #3 allegedly pushed resident #1 off the sidewalk and hit them. But the incident was part of a longer pattern of harassment that staff had observed and failed to control.

CNA #2 told inspectors that resident #1 regularly called resident #3 "a retard" and that resident #3 "would get mad." The staff member said she was "unsure what to do" because when staff told resident #1 to stop making derogatory statements, "resident #1 would increase the statements."

The verbal abuse was specific and cruel. On one occasion, resident #1 told a staff member: "When you are done playing with the retard, I need a napkin." On another: "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. Resident #3 would remain in their room to avoid resident #1 when they shared a house, staff reported. CNA #2 said resident #3 "was fearful" following the September 19 attack.

Six days later, the violence escalated again.

On September 25, resident #1 woke up upset and began "calling people derogatory names," according to CNA #3. When staff told resident #1 they couldn't make a phone call, the resident became more agitated and "chased after the CNA."

The staff member called security. Resident #2, who had been trying to avoid the conflict by staying in their room, heard resident #1's statements and "grabbed some water" before heading to resident #1's room.

By the time the CNA reached the room, "resident #1 was soaked and resident #2 was trying to punch resident #1 while resident #1 was hitting resident #2 on top of the head with a television remote."

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

The pattern of conflict involved multiple residents. CNA #2 explained that resident #2 "had gone after resident #1 because resident #2 was protective of staff and other residents and resident #1 antagonized other residents and staff."

Staff described resident #2 as someone who "often stayed in his/her room to avoid resident #1."

RN #1 confirmed the broader pattern, telling inspectors that resident #1 "had other incidents with individuals due to derogatory statements" and that resident #2 "had been in incidents with resident #1 after resident #1 had made derogatory statements to others."

The facility's own policy, dated May 14, 2025, states: "It is the policy and practice of the WLRC that all residents will be protected from abuse and neglect."

But staff interviews revealed their interventions were ineffective. CNA #3 said that when staff attempted to redirect resident #1, "it was not always effective." The pattern suggests that verbal redirection was the primary tool used, despite its documented failure to prevent escalation.

The non-verbal resident #3 bore the brunt of the harassment. RN #1 said resident #3 "got along with everyone except resident #1 because s/he called resident #3 retarded."

After the September 19 attack, when asked if they were okay, resident #3 could only shake their head no and point to their injuries. The resident's fear was palpable to staff, who noted the change in behavior.

The facility failed to implement effective measures to prevent the abuse despite clear warning signs. Staff witnessed the verbal harassment repeatedly but couldn't develop strategies to stop it. The physical environment allowed the conflicts to continue, with residents living in close proximity despite the documented antagonism.

Federal inspectors determined the facility violated regulations requiring protection from abuse and neglect, finding that "few" residents were affected but that "actual harm" occurred.

The inspection was conducted in response to a complaint, suggesting someone outside the facility reported the incidents when internal systems failed to address them.

Resident #3 remains at the facility, still non-verbal, still vulnerable to the resident who calls them slurs and has physically attacked them. The black eye has healed, but the fear remains visible to staff who watch the resident point to old injuries when asked about their wellbeing.

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.

Additional Resources

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