Mountain City Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Mountain City Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 31, 2024

  Based on review of clinical records and select facility policy, observations, and staff and resident interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor a resident's whereabouts and prevent an elopement by one resident (Resident 181) out of 14 sampled residents, placing the 65 residents out of 238 residents residing in the facility, identified at risk for elopement, including Resident 142, in immediate jeopardy to their health and safety. Findings include: Review of facility policy entitled Elopement/ Unauthorized absence, last revised by the facility February 6, 2024, revealed that elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. […]

• Actual harm, patternF600Apr 19, 2024

  Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and staff interviews, it was determined that the facility failed to ensure that six residents (Residents 212, 93, 203, 178, 487, and 152) were free from physical abuse perpetrated by other residents (Residents 3, 188, 225, 212, 221, 213, and 56) out of 41 residents sampled for abuse prevention, which resulted in serious harm and injury to one resident, a fractured leg and hip (Resident 203). […]

• Actual harm, isolatedF689Jan 12, 2026

  Based on review of clinical records, facility policy, observations, facility-provided investigative documentation, security camera evidence, and resident and staff interviews, it was determined that the facility failed to ensure appropriate supervision and implementation of safety interventions to protect a resident from accident hazards (medications) and elopement from the facility. This failure resulted in actual physical harm for one out of 10 residents sampled (Resident 1). […]

• Actual harm, isolatedF600Jul 10, 2024

  Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and interviews with staff, residents and resident representatives, it was determined that the facility failed to ensure that one resident was free from sexual abuse and resultant psychosocial harm (Resident 16) and that one resident (Resident 106) was free from physical abuse out of 11 residents sampled for abuse prohibition. Findings include: A review of a facility policy entitled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation, dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. […]

• Actual harm, isolatedF805May 31, 2024

  Based on review of clinical records, the facility's diet manual and select facility incident reports, and staff interviews, it was determined that the facility failed to ensure that a resident identified with swallowing difficulties was consistently served food in a form to meet the resident's individual needs, which caused a choking incident and aspiration (when food, drink, or foreign objects are breathed into the lungs) requiring hospitalization of one of 14 residents reviewed (Resident 196). Findings Include: Review of Resident 196's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of dysphagia (difficulty swallowing). […]