Mountains Community Hosp DP/SNF

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control guidelines for a universe of 19 residents when expired medical supplies were found in procedure cart and medical supply room and were readily available for use. This failure had the potential to cause unsafe care provided to the facility's 19 residents with beyond the use date (expired) supplies, which could potentially cause infection, injuries, and/ or death. Findings: During a concurrent observation and interview on [DATE], at 6:10 AM, in the facility's treatment cart and medical supply room, with the Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN 2). The medical supplies were observed as follows: 1. 41 safety intravenous (IV) catheters (a thin, flexible tube inserted into vein to deliver fluids, medications or blood products directly into the blood stream) Size 24 gauge (size of catheter) with an expiration date of [DATE] (3 days expired). 2. Nine IV extension set (flexible tube used to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Resident Assessment Instrument/Minimum Data Set (RAI/MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) for a change of condition was completed within 14 days as stated within their policy and procedures (P&P) and in accordance with the federal submission timeframes for one of eight sampled residents (Resident 6) when Resident 6's condition was changed from having clear speech and no impairment with movements to unable to lift right arm, speech was very weak and was having difficulty making a sentence. This failure resulted in inadequate monitoring of Residents 6 and had the potential to delay necessary interventions leading to deterioration, increased risk of complications and poor resident prognosis. Findings: During a review of Resident 6 Progress note, dated April 20, 2025, the Progress note indicated, Resident 6 was admitted to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Resident Assessment Instrument/Minimum Data Set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was completed accurately for one of eight sampled residents (Resident 6) when the MDS assessment did not show Resident 6's current condition of having functional limitations to the right upper extremity and speech impairments. This failure resulted in inaccurate documentation of assessment for Residents 6 and had the potential to cause inadequate care planning, delay of necessary interventions that can lead to deterioration, increased risk of complications and poor resident prognosis. Findings: During a review of Resident 6 Progress note, dated April 20, 2025, the Progress note indicated, Resident 6 was admitted to the facility on [DATE] and had diagnoses including diabetes (a group of diseases that result in too much sugar in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record reviews, the facility failed to establish a comprehensive care plan (an individualized plan that includes residents' health problems, preferences and goals) consistent with the resident's medical needs for one of four residents (Resident 6) when the facility staff did not update Resident 6's care plan after identifying a change of condition. This failure resulted in inadequate response to Resident 6's changing needs, and had the potential increased risk of harm, delayed treatment, and reduced quality of life. Findings: During a review of Resident 6 Progress note, dated April 20, 2025, the Progress note indicated, Resident 6 was admitted to the facility on [DATE] and had diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), hypertension (high blood pressure), chronic kidney disease (damage to the kidneys that persists for at least three months), and right tibial fracture (a break in the larger bone in the lower leg). During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 9) was free from significant medication error, when a furosemide (a medication commonly called as water pill that used to eliminate water and salt from the body) was held for a systolic blood pressure (the top number in a blood pressure reading and represents the pressure in the arteries when the heart beats) less than 100 without a hold order. This failure resulted in lack of appropriate documentation and had the potential to cause adverse health outcomes by not achieving the effective purpose of the medication and miscommunication amongst the following nursing staff. Findings: During a review of Resident 9's History and Physical (H&P- a formal assessment document by the physician), dated April 30, 2025, the H&P indicated, Resident 9 was admitted on [DATE], with diagnoses of benign prostatic hyperplasia (BPH-refers to a non-cancerous enlargement of the prostate gland, hypothyroidism (when your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain professional standards for food safety when: 1.The ice machine was found to have black build up. 2.The dishwashing machine was not sanitizing. 3.There was no air gap (a separation between the water supply and potentially contaminated water in a sink or other plumbing fixture) found at the food preparation sink. The facility's failures to ensure a safe and sanitary kitchen resulted in the increased risk of resident harm from food-borne illness (food poisoning that can cause nausea, vomiting, and diarrhea) to a population of 18 immuno-compromised (decreased ability to fight off infections and diseases) residents who received food from the kitchen. Findings: 1.During a concurrent observation and interview with the Director of Facilities (DOF) and the Lead Facilities Technician (LFT), on April 17, 2023, at 12:40 PM, the ice machine was observed to have black build up around the motor of the ice machine and the metal part of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to properly close the dumpster (large outdoor trash container) lids when two of eight dumpsters were found with trash bags exceeding the fill line of the dumpster. This failure had the potential to attract vermin (pest or animals that spread diseases) in the facility that cares for 18 medically compromised residents. Findings: During a concurrent observation and interview with the Registered Dietician/ Dietary Supervisor (RD/ DS), on April 17, 2023, at 12:04 PM, the outdoor garbage storage area had two dumpsters with trash bags exceeding the fill line of the dumpster, with the lids not fully closed. The RD/DS stated, the lids should be fully closed. During a concurrent observation and interview with the Environmental Service Manager (ESM), on April 17, 2023, at 12:07 PM, the ESM verified the two dumpsters had trash bags exceeding the fill line, preventing the lids from being fully closed. The ESM stated, the dumpster lids should always be closed because of the risk of attracting vermin. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their Policy and Procedure (P&P) for transmitting resident's assessment data (tool that provides overview of the resident's condition) within the required timeframe outlined by Federal Regulations for three of four sampled residents (Resident 3, Resident 17, and Resident 10). This failure had the potential to result in a delay in determining the resources necessary to competently care for the residents during the day to day operations and emergencies. Findings: 1.During a review of Resident 3's admission Record (a document that contains demographic and clinical data), the admission Record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes (high sugar levels), chronic (long term) back pain, and hypertension (raised pressure against the vessel walls). During a concurrent interview and record review, on April 20, 2023, at 8:20 AM, with the MDS Nurse, Resident 3's Minimum Data Set 3.0( MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to complete a Physician Orders for Life-Sustaining Treatment ([POLST] medical order form that provides instructions to medical staff on what to do in the event of a medical emergency) for one of 18 sampled residents (Resident 15). This failure could have resulted in Resident 15's medical treatment wishes not being followed. Findings: During a review of Resident 15's clinical record titled, History and Physical Examination (H&P- a document that contains past and current medical history) - Final Report, dated, January 15, 2020, at 2:50 PM, by Physician 1 (Phys. 1), indicated, Resident 15 had a past history of stroke (an event where there is oxygen deprivation to the brain), diabetes (inability to control blood sugar), and Chronic Kidney Disease (kidneys do not efficiently filter out waste products). During a review of Patient 15's clinical record titled, Section C Cognitive (thinking, understanding, remembering) Patterns (a section of the Minimum Data Set ([MDS] assessment tool used to assess cognitive skills for decision…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to follow their Policies and Procedures (P&P) regarding infection control practices during an eye drop medication administration for one of eighteen sampled residents (Resident 16). This failure had the potential to introduce bacteria into one resident's eyes in a population of eighteen sampled residents (Resident 16). Findings: During a review of Resident 16's clinical record titled, History and Physical (H&P- past and current medical history) Examination- Final Report , dated, July 19, 2021, at 2:26 PM, by Physician (Phys. 1) indicated, Resident 16's diagnoses included Type 2 Diabetes (inability to control blood sugar), Congestive Heart Failure (CHF- condition in which the heart does not pump blood efficiently), and yeast dermatitis (fungal infection on the skin). During an observation on April 19, 2023, at 6:44 AM, inside Resident 16's room, with the Licensed Vocational Nurse (LVN 1), observed the LVN 1 put on gloves, electronically scan (hand held scanner) Resident 16's name card (card that contains the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.