Mountain City Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 26, 2024

  Based on review of facility reported incident investigation documents and medical records, interviews and observations it was determined that the facility failed to provide adequate supervision to prevent a vulnerable resident from exiting the facility unattended by staff. This was found to be evident for 1 (Resident #234) out of 3 residents reviewed in relation to facility self reports of elopement during the survey. The findings include: Review of Resident #234's medical record revealed the resident was admitted to the facility in December 2021 with multiple psychiatric diagnosis which included paranoid schizophrenia. In November 2022 the resident was receiving multiple psychoactive medications including an antipsychotic, an antidepressant and antianxiety medications. […]

• Actual harm, isolatedF689Nov 7, 2025

  Based on facility policy review, record review, facility document review, interview, and observation, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, which affected 4 (Resident #8, #7, #12, and #18) of 9 residents reviewed for accidents or falls during the complaint survey. Specifically, Resident #8 was improperly transferred by one staff when they required two staff to safely transfer causing actual harm. The Findings include: A facility policy titled, Assessing Falls and Their Causes, revised 03/2018, revealed, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The policy revealed, Preparation included, 1. […]

• Actual harm, isolatedF686Nov 26, 2024

  Based on medical record review, observation and interview it was determined that the facility failed to provide care to prevent the development of pressure ulcers. This was found to be evident for one(Resident #34) out of four residents reviewed for pressure ulcers during the survey. This deficient practice resulted in actual harm to Resident #34. The findings include 1.) On 11/13/24 review of Resident #34's medical record revealed the resident has resided at the facility for several years and whose diagnosis include but are not limited to, dementia, osteoporosis, high blood pressure, and hypothyroidism. The resident had two pressure ulcers, one on each foot, with orders for daily dressing changes. […]

• No harm, potential for more than minimal, widespreadF851Nov 26, 2024

  Based on record review and interview it was determined that the facility failed to submit their Payroll Based Journal (PBJ) information to Medicare. This was evident in the off-site preparation portion and during the on-site recertification survey. The findings include: During the off-site preparation for the recertification survey, the survey team was provided a copy of the facility's Payroll Based Journal Report which indicated that no data was submitted. On 11/12/24 at 9:31 AM during the entrance conference with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) the surveyor provided the [NAME] report and PBJ staffing Data Report which indicated that no data was submitted for the 3rd quarter which ended June 30, 2024. […]

• No harm, potential for more than minimal, patternF628Mar 6, 2026

  Based on record review and interview it was determined that the facility failed to provide the required information to the resident and their representatives at the time of discharge to the hospital; and failed to ensure required documents were sent with the resident to the hospital at the time of transfer. This was found to be evident for two (Resident #6 and #9) out of three residents reviewed for hospitalization.The findings include: 1) Review of Resident #6's medical record revealed the resident was a long-term care resident who has resided at the facility for more than a year. On 2/23/26 the resident was transferred from the facility to the hospital, where the resident was admitted . […]