South Mountain HC

In the surveyor’s words

From the most serious findings on record at South Mountain HC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF803Aug 25, 2025

  Based on observation, interviews and review of pertinent facility documents, it was determined that the facility failed to ensure the development and implementation of menus to consistently provide adequate portions of milk and bread to residents in accordance with the facility's diet manual, policy and national nutritional standards for a four-week cycle menu. This deficient practice was evidenced by the following:On 8/18/25 at 8:59 AM, during entrance conference it was determined that the facility was licensed for a capacity of 195 beds and had a current census of 189 beds.On 8/18/25 at 10:13 AM, the surveyor toured the kitchen with the Food Service Director (FSD) in the presence of a second surveyor. […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2025

  Based on observations, interviews, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness.This deficient practice was observed during two kitchen tours and was evidenced by the following:On 8/18/25 at 10:13 AM, the surveyor toured the kitchen with the Food Service Director (FSD), in presence of a second surveyor and observed the following:To the left of the handwashing sink, and to the right of the walk-in freezer, there was a damaged wall with a penetration, which the FSD stated had been that way since she started in May 2025 and the Director of Maintenance (DOM) was aware. […]

• No harm, potential for more than minimal, widespreadF925Aug 25, 2025

  Based on observations, interviews and review of pertinent facility documents, it was determined that the facility failed to implement an effective pest control program in the kitchen.This deficient practice was evidenced by the following:On 8/18/25 at 10:13 AM, the surveyor toured the kitchen with the Food Service Director (FSD), in presence of a second surveyor. The surveyors observed a live bug walking up a white tiled wall above a stainless-steel table which had food preparation equipment on it, uncovered.The FSD observed the bug as well and stated, we have a pest control problem here; it was like this when I got here; maintenance is aware; we have a company [name redacted] that comes every Tuesday.The surveyors then observed two live bugs walking on the floor, in the dry storeroom. […]

• No harm, potential for more than minimal, widespreadF812May 16, 2024

  Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure: a) a consistent system for labeling and dating was implemented to ensure all potentially hazardous foods were labeled with a use by date, b) the kitchen environment, all equipment and dishware was maintained in a clean and sanitary manner and transported appropriately, and c) staff performed appropriate hand hygiene, to limit the potential for contamination, and the risk of potential foodborne illness. The deficient practice was evidenced by the following: On 05/08/24 at 9:26 AM through 10:40 AM, the surveyor conducted a tour of the kitchen with the Registered Dietitian (RD) and the Food Service Director (FSD) and observed the following: 1. […]

• No harm, potential for more than minimal, patternF607May 16, 2024

  Based on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to implement the facility's abuse policy to ensure reference checks were completed for Ten (10) of Ten (10) newly hired staff reviewed. This deficient practice was evidenced by the following: On 05/14/24, the surveyor reviewed Ten (10) randomly new employee files which revealed the following: Staff #1-a Certified Nursing Assistant (CNA), with a hire date of 09/22/22, did not have a previous employee reference on file. Two (2) undated typed personal reference letters were on file. Staff #2-a CNA, with a hire date of 04/12/24, did not have a previous employee reference on file. […]