Hibriten Mountain Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Hibriten Mountain Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF742Mar 21, 2022

  Based on record review, resident, staff, Psychologist, Nurse Practitioner, and Medical Director interviews the facility failed to: 1) assess a resident's [CONDITION(S)] and suicide attempt to determine underlying causes, 2) document a suicide attempt and communicate the attempt with the resident's behavioral health provider to coordinate care, and 3) develop a plan of care with individualized care approaches and provide ongoing assessment of the care approaches to ensure resident's psychiatric health needs were being met for 1 of 1 resident reviewed for behavioral health services (Resident #36) who reported suicide ideations on [DATE] and then acted upon her [CONDITION(S)] by placing a plastic bag over her head on [DATE] in an attempt to suffocate herself. […]

• Immediate jeopardy, isolatedF689Jul 22, 2025

  Based on record review, observations, and interviews with the resident's responsible party, staff, and the Medical Director, the facility failed to supervise a severely cognitively impaired resident who demonstrated wandering behaviors in the facility and prevent him from entering into an unlocked kitchen door and then exiting the facility through the kitchen's exterior door for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 who had a diagnosis of dementia exited from the facility without staff's knowledge for an undetermined length of time on the evening of 7/11/25 and was observed by staff through the door at the end of C hall standing by the facility's transport van parked outside the facility in the back parking lot in socked feet. […]

• Immediate jeopardy, isolatedF602Dec 17, 2024

  Based on record review, and resident, staff, and detective interviews, the facility failed to protect the resident's (Resident #70) right to be free from misappropriation of property when Housekeeper #1 used Resident #70's debit card to set up a mobile payment application account on his [Housekeeper #1's] phone without Resident #70's permission or knowledge. Housekeeper #1 was alleged to have sent approximately $4,000.00 of unauthorized payments from Resident #70's bank account to his mobile payment application account from February 2024 to May 2024. Resident #70 stated, I am poor and he took everything I had. He indicated he was very upset that someone he trusted had taken advantage of him and he was worried to death over the loss of money and the potential for identity theft. […]

• Immediate jeopardy, isolatedF551Sep 7, 2021

  Based on record review and interviews with the Legal Guardian (LG), resident, staff, and the Nurse Practitioner (NP), the facility failed to follow instructions from the LG and allowed Resident #1 to leave the facility with an unauthorized person. Resident #1 was later diagnosed with aspiration pneumonia. This situation affected 1 of 3 residents reviewed for accidents. Immediate Jeopardy began when Resident #1 was signed out of the facility on 8/14/21 without consent from the LG. Immediate Jeopardy was removed on 8/21/21 when the facility provided and implemented an acceptable credible allegation for removal. […]

• Immediate jeopardy, isolatedF835Sep 7, 2021

  Based on record review and interviews with the Legal Guardian (LG), resident, staff, and the Nurse Practitioner (NP), the administration failed to provide oversight and leadership to Department Heads (DH) and direct care staff to effectively communicate which residents were assigned legal guardianship and ensure a guardian's directive to only leave the facility with authorized persons was followed for 1 of 3 resident (Resident#1) reviewed for accidents. Immediate Jeopardy (IJ) began on 08/13/21 when the facility's administration failed to effectively communicate to DH and direct care staff which residents were assigned a LG and failed to communicate the LG's directives that a resident could not leave the facility with an unauthorized person. […]