Mountain Manor Senior Residence

In the surveyor’s words

From the most serious findings on record at Mountain Manor Senior Residence, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 27, 2023

  Based on interview and record review, the facility failed to protect 2 of 5 sampled residents (Resident 3 and Resident 4) and ensure they were free from physical abuse when: 1. Resident 3 struck and hit Resident 4 on his face and arms; 2. The facility could not provide adequate care for Resident 3's history of combative behaviors; and, 3. The facility did not follow their policy to accurately monitor Resident 3 for behaviors of agitation. This failure resulted in Resident 4 being transferred to the Emergency Department (ED) for facial injuries and not feeling safe at the facility, and Resident 3 being taken into police custody. […]

• No harm, potential for more than minimal, widespreadF812Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety, when: 1. The ice machine was not clean; 2. The blade of the can opener was not well maintained; 3. Significant scratches were found on the cooking surfaces on the nonstick cooking pans with coating; 4. Significant amount of food items were found with inconsistent dating practices in the reach-in refrigerators, dry storage and walk-in freezer; 5. Opened food packages were found not resealed properly; 6. The thawing meat was found with no pull date to indicate when the meat thawing started; 7. Produce food items were found not fresh; and 8. […]

• No harm, potential for more than minimal, widespreadF812Jun 6, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. The ice machine was not clean with black and pink substances at the bottom of the ice evaporator unit (a part where water freezes to produce ice and push out from the unit) and pink slimy substances on the water curtain (a plastic cover rests over the ice evaporator where the ice dispenses); 2. There were 11 out 15 tomatoes with black and white indented spots found in dry storage; 3. There were several metal pans found stacked wet and contained food debris when stored at the clean and ready-to-use storage areas; 4. Employee's personal belonging found in the dry food storage area; and, 5. […]

• No harm, potential for more than minimal, widespreadF730May 11, 2023

  Based on interview and record review, the facility failed to complete the annual performance reviews for eight of eight sampled certified nursing assistants (CNAs; CNA 1, CNA 2, CNA 3, CNA 4, CNA 5, CNA 6, CNA 7, and CNA 8). This failure increased the residents' potential to receive poor quality of care from CNAs. Findings: A review of the New Hire Report, dated 5/10/23, indicated, CNA 1's date of hire (DOH) was 11/13/20, CNA 2's DOH was 9/8/20, CNA 3's DOH was 9/5/18, CNA 4's DOH was 10/29/19, CNA 5's DOH was 8/16/21, CNA 6's DOH was 8/1/14, CNA 7's DOH was 7/6/19, and CNA 8's DOH was 3/15/17. […]

• No harm, potential for more than minimal, widespreadF880Feb 4, 2022

  Based on observation, interview, and record review the facility failed to ensure infection control measures were observed and maintained for a census of 47 when: 1. The facility did not designate a red zone for Covid-19 positive residents; 2. The staff did not change PPE (personal protective equipment) between residents; 3. The staff did not have PPE readily available; and 4. The facility did not maintain and prevent cross- contamination. These failures increased the risk for the spread of Covid-19 infections (A virus that causes mild to severe respiratory infections) to a vulnerable patient population. 1. During an observation and concurrent interview on 1/31/22, at 11:30 a.m., three rooms on hallway 1 and two rooms on hallway 2 were observed with zippered plastic covering their doors. […]