Embassy of East Mountain

In the surveyor’s words

From the most serious findings on record at Embassy of East Mountain, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 9, 2026

  Based on observations, review of clinical records, review of select facility policies and information submitted by the facility, and staff interviews, it was determined that the facility failed to provide adequate staff supervision of a resident to monitor the resident's whereabouts and timely identify the resident's absence from the facility to assure prompt implementation of established procedures for a missing resident, which placed the resident in immediate jeopardy for one out of 19 residents sampled (Resident 26). […]

• Actual harm, isolatedF689Feb 16, 2022

  Based on a review of clinical records and select facility reports, and staff interview it was determined that the facility failed to provide sufficient staff supervision and assistance with activities of daily living to prevent a fall for a resident identified at high risk for falls that resulted in a fracture of the right hip and right distal humerus (lower end of the upper arm bone, one of the three bones that come together to form the elbow joint) for one resident (Resident 75) out of nine residents reviewed. Findings include: A review of the clinical record revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses, which included [CONDITION(S)]. […]

• No harm, potential for more than minimal, widespreadF925May 17, 2023

  Based on observations, a review of pest control records and resident and staff interviews it was determined that the facility failed to maintain an effective pest control program as evidence of pest infestation was observed in resident rooms and the facility's dietary department. Findings include: Observation of resident room [ROOM NUMBER] on May 17, 2023, at 9:30 a.m., revealed numerous rodent droppings, which appeared to be mouse droppings, in areas throughout the residents room, including on the resident's clothing in the dresser drawers. Interview with Resident 3, who resides in room [ROOM NUMBER] at that time stated that she just makes sure to keep her feet up off the floor to avoid the mice. The resident stated that she has seen mice in her room recently. […]

• No harm, potential for more than minimal, patternF565Jan 9, 2026

  Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances filed with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by five of five residents attending a resident group meeting (Residents 51, 58, 63, 73, and 99) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.Findings include: A review of the facility's Grievance Policy last reviewed on January 16, 2025, indicated the residents', families, and their representatives have the right to voice… […]

• No harm, potential for more than minimal, patternF584Jan 9, 2026

  Based on observations and resident and staff interviews, it was determined the facility failed to maintain a safe, sanitary, and homelike environment in two out of three resident shower rooms (East and West). Findings include: During a resident council meeting on January 7, 2026, at 10:10 AM, interviews with five cognitively intact residents, Residents 73, 51, 58, 63, and 99, it was reported during the month of December through present, the temperatures inside the East shower room was frequently cold and uncomfortable and the [NAME] shower room's hot water intermittently went cold during showers and was uncomfortable. All residents reported nursing staff were aware, but nothing was addressed. […]