Black Mountain Neuro-Medical Treatment Center

In the surveyor’s words

From the most serious findings on record at Black Mountain Neuro-Medical Treatment Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Mar 24, 2023

  Based on record review, staff and physician interviews, the facility failed to prevent a significant medication error when Nurse #1 administered medications to Resident #8 that were prescribed for Resident #58 for 1 of 2 sampled residents reviewed for hospitalization . On the morning of 11/23/22, Resident #8 received six medications which included Depakote (mood stabilizer), Bumex (diuretic), Gabapentin (used to treat nerve pain), Metoprolol (used to treat blood pressure), Risperdal (antipsychotic), and Sertraline (antidepressant). On 11/23/22 at 11:50 AM, Resident #8 appeared lethargic (decreased alertness) and was assessed by Nurse #1 to have a heart rate of 43 and her blood pressure reading could not be obtained. […]

• No harm, potential for more than minimal, patternF812Aug 15, 2024

  Based on observations and staff interviews the facility failed to discard food items past the use by date in 1 of 2 reach-in coolers; discard food with signs of spoilage in 2 of 2 walk-in coolers; and label and date two bags of unidentifiable frozen food items that had been removed from the original container in 1 of 1 reach-in freezer. This failure had the potential to affect food served to residents. Findings included: a. An observation with the Food Service Director of the reach-in cooler on [DATE] at 9:27 AM revealed the following: A package of sliced white cheese with an opened date of [DATE]. A package of sliced yellow cheese with an opened date of [DATE]. A 4.5 ounce jar of minced garlic with an open date of [DATE]. […]

• No harm, potential for more than minimal, patternF641Mar 24, 2023

  Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the area of Preadmission Screening and Resident Review (PASRR) for 6 of 6 sampled residents reviewed for PASRR (Residents #4, #11, #12, #15, #16, and #37). Findings included: 1. Resident #4 was admitted to the facility on [DATE]. His diagnoses included schizophrenia, anxiety disorder, and depression. The annual MDS assessment dated [DATE] indicated Resident #4 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. […]

• No harm, potential for more than minimal, isolatedF600Aug 15, 2024

  Based on record review and interviews with staff and the Nurse Practitioner, the facility failed to protect the resident's right to be free from neglect when Nurse Aide (NA) #1 started providing incontinence care for Resident #2 without assistance and was aware of the plan of care instructions for 2-person assist. NA #1 turned away from the bed to reach supplies and Resident #2 rolled off the raised bed onto the fall mat. The deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury and osteoporosis. […]

• No harm, potential for more than minimal, isolatedF757Mar 24, 2023

  Based on record reviews and interviews with staff, Consultant Pharmacist, and Medical Director, the facility failed to monitor the cholesterol level for 1 of 5 residents reviewed for unnecessary medications (Resident #68). The findings included: Review of lipid guidelines published in 2019 by American College of Cardiology and American Heart Association indicated lipid panel should be conducted at baseline, then 4 to 12 weeks after statin therapy was started or when dosage was adjusted. Afterwards, lipid panel test should be repeated once every 3 to 12 months or as needed. Resident #68 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, coronary artery disease, high blood pressure, and hyperlipidemia. […]