Mountains Community Hosp DP/SNF

In the surveyor’s words

From the most serious findings on record at Mountains Community Hosp DP/SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Jun 5, 2025

  Based on observation, interview, and record review, the facility failed to follow infection control guidelines for a universe of 19 residents when expired medical supplies were found in procedure cart and medical supply room and were readily available for use. This failure had the potential to cause unsafe care provided to the facility's 19 residents with beyond the use date (expired) supplies, which could potentially cause infection, injuries, and/ or death. Findings: During a concurrent observation and interview on [DATE], at 6:10 AM, in the facility's treatment cart and medical supply room, with the Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN 2). The medical supplies were observed as follows: 1. […]

• No harm, potential for more than minimal, widespreadF812Apr 20, 2023

  Based on observations, interviews, and record reviews, the facility failed to maintain professional standards for food safety when: 1.The ice machine was found to have black build up. 2.The dishwashing machine was not sanitizing. 3.There was no air gap (a separation between the water supply and potentially contaminated water in a sink or other plumbing fixture) found at the food preparation sink. The facility's failures to ensure a safe and sanitary kitchen resulted in the increased risk of resident harm from food-borne illness (food poisoning that can cause nausea, vomiting, and diarrhea) to a population of 18 immuno-compromised (decreased ability to fight off infections and diseases) residents who received food from the kitchen. […]

• No harm, potential for more than minimal, widespreadF814Apr 20, 2023

  Based on observations, interviews, and record reviews, the facility failed to properly close the dumpster (large outdoor trash container) lids when two of eight dumpsters were found with trash bags exceeding the fill line of the dumpster. This failure had the potential to attract vermin (pest or animals that spread diseases) in the facility that cares for 18 medically compromised residents. Findings: During a concurrent observation and interview with the Registered Dietician/ Dietary Supervisor (RD/ DS), on April 17, 2023, at 12:04 PM, the outdoor garbage storage area had two dumpsters with trash bags exceeding the fill line of the dumpster, with the lids not fully closed. […]

• No harm, potential for more than minimal, isolatedF657Jul 30, 2026

  Based on interview and record review, the facility failed to ensure residents' comprehensive care plan (person centered, individualized roadmap used to outline specific care interventions for a nursing home resident) was updated to address psychotropic (chemical that affects how the brain works, changing a person mood) medications for one of two sampled residents (Resident 13) .This failure had the potential to result in inconsistent implementation of care, missed monitoring for effectiveness, adverse side effects (harmful, unintended reactions to medications), lapses on non-pharmacological interventions (evidence-based non-drug methods used to prevent or manage symptoms), and individualized approaches to care. […]

• No harm, potential for more than minimal, isolatedF637Jun 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure the Resident Assessment Instrument/Minimum Data Set (RAI/MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) for a change of condition was completed within 14 days as stated within their policy and procedures (P&P) and in accordance with the federal submission timeframes for one of eight sampled residents (Resident 6) when Resident 6's condition was changed from having clear speech and no impairment with movements to unable to lift right arm, speech was very weak and was having difficulty making a sentence. […]