Blue Mountain Care Center

In the surveyor’s words

From the most serious findings on record at Blue Mountain Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF725Oct 17, 2025

  Based on interview, and record review it was determined the facility failed to ensure a licensed nurse was on duty for 1 of 2 days reviewed for licensed nurse staffing. This placed residents at risk for delayed and unmet medical needs. Findings include: On 10/14/25 at 6:07 PM Staff 17 (Former DNS) stated there was one occasion on 8/6/25 or 8/7/25 when there was no nurse working on night shift. On 10/15/25 at 9:43 AM a request was made from Staff 1 (Administrator) for the Direct Care Staff Daily Reports and the daily staff assignment sheets from 8/6/25 and 8/7/25.On 10/15/25 at 10:18 AM Staff 21 (Quality Coordinator) stated she was unable to locate the daily staff assignment sheets for 8/6/25 and 8/7/25. […]

• No harm, potential for more than minimal, widespreadF727Oct 17, 2025

  Based on interview and record review it was determined the facility failed to ensure a registered nurse was available for at least eight consecutive hours for 3 of 17 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include:A review of the Direct Care Staff Daily Reports for 9/1/25 and 10/1/25 through 10/16/25 revealed the following dates without the required RN coverage:-9/1/25-10/6/25-10/7/25On 10/16/25 at 4:53 PM Staff 1 (Administrator) acknowledged the identified dates without the required RN coverage.

• No harm, potential for more than minimal, widespreadF732Oct 17, 2025

  Based on interview and record review it was determined the facility failed to post accurate and complete staffing information and failed to retain required staff postings for 1 of 1 facility reviewed. This placed residents and the public at risk for incomplete and inaccurate staffing information. Findings include:a. On 10/15/25 at 9:43 AM a request was made from Staff 1 (Administrator) for the Direct Care Staff Daily Reports from 8/1/25 through 10/14/25.On 10/15/25 at 2:18 PM Staff 1 stated she was unable to locate the Direct Care Staff Daily Reports for 8/1/25 through 8/31/25 and 9/2/25 through 9/30/25.b. A review of the Direct Care Staff Daily Reports from 10/1/25 through 10/16/25 revealed 16 of 16 days when portions of the form were left blank, crossed out, or were inaccurate. […]

• No harm, potential for more than minimal, widespreadF835Oct 17, 2025

  Based on interview and record review it was determined the facility administration failed to use resources effectively and efficiently to attain or maintain the residents' highest practicable physical, mental and psychosocial well being. Deficient practice was noted related to a lack of staffing, a failure to retain staff postings, infection control, physician visits, social services, and resident rights for 1 of 1 facility reviewed for effective administration. Findings include:1.The facility failed to offer the resident/representative opportunities to participate in their care planning process via care conference for four identified residents (#s 3, 4, 6, and 13). […]

• No harm, potential for more than minimal, widespreadF851Oct 17, 2025

  Based on interview and record review it was determined the facility failed to submit mandatory staffing information based on the payroll data journal and other verifiable and auditable data as required. This placed residents at risk for inaccurate staffing information. Findings include:A review of the Payroll Based Journal Staffing Data for Fiscal Year Quarter 1 and Quarter 2 of 2025 (April 1-June 30) indicated the facility failed to submit required data for the two quarters.On 10/15/25 at 2:40 PM Staff 1 (Administrator) confirmed the Payroll-Based Journal was not submitted.