Cycle 1
Health 2025-05-01 · Fire 2025-05-01
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Denton, NC
Mountain Vista Health Park
5-star overall rating with 5-star inspections
106 Mountain Vista Health Park Road, Denton, NC
(336) 859-2181
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
54
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-02-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.65
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.12
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
5.32
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,007
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.12
Composite VBP score used to determine payment impact.
Payment multiplier
1.0162
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.90
Baseline 19.66% · Performance 21.02% · Measure score 0.90 · Achievement 0.90 · Improvement 0
Healthcare-associated infections
5.64
Baseline 6.28% · Performance 6.15% · Measure score 5.64 · Achievement 5.64 · Improvement 0.49
Total nurse turnover
10
Baseline 23.81% · Performance 14.52% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
7.90
Baseline 4.40 hours · Performance 5.33 hours · Measure score 7.90 · Achievement 7.90 · Improvement 6.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.78% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 56 · Observed rate 8.93% · Lower 95% interval 7.09% |
| Discharge to community | 45.26% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 43.33% · Lower 95% interval 36.03% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.83% |
95.27%
0.6 pts better
|
Numerator 23 · Denominator 24 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 1 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 1 · Denominator 24 · Adjusted rate 4.72% |
| Healthcare-associated infections requiring hospitalization | 6.15% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 0% · Lower 95% interval 2.78% |
| Staff COVID-19 vaccination coverage | 0.6% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 168 |
| Staff flu vaccination coverage | 12.5% |
42%
29.5 pts worse
|
Numerator 21 · Denominator 168 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.6%
2.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
4.8%
1.4 pts worse
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.3% · Q3 6.4% · Q4 9.1% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
7.2%
2.9 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 9.5% · Q3 5.0% · Q4 0.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
21.6%
5.3 pts better
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 16.7% · Q3 12.2% · Q4 12.5% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
15.0%
9.8 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.3% · Q3 5.1% · Q4 8.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.6% |
21.5%
2.9 pts better
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 18.3% · Q4 18.4% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.4% |
16.8%
6.6 pts worse
|
14.9%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 21.6% · Q3 24.3% · Q4 22.2% · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.9%
0.6 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
2.6%
1.5 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.1% · Q3 2.1% · Q4 2.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
21.2%
2.5 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 21.7% · Q3 12.2% · Q4 23.8% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
6.0%
5.2 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
79.9%
20.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
78.1%
10 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-09-01 · Fire 2022-09-01
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-02-01
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-03-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-09-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-22
Penalties and ownership
What sits behind the stars
Ownership
Morris, Scott
5% Or Greater Direct Ownership Interest · Individual
Montgomery, Cynthia
Operational/Managerial Control · Individual
Montgomery, Cynthia
Corporate Director · Individual
Morris, Scott
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Piedmont Crossing
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Lexington Health Care Center
Lexington, NC
1-star overall rating with 2-star inspections with abuse icon flag with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Pine Acres Center for Nursing and Rehabilitation
Lexington, NC
1-star overall rating with 1-star inspections with $122,460 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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