South Mountain Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Apr 22, 2026

  Based on a pertinent document review and interviews, it was determined that the facility failed to provide an Emergency Medical Service (EMS) transport crew with the correct Medical Orders for Life-Sustaining Treatment (MOLST) for a resident being transported to the hospital, This deficient practice contributed to the resident not receiving life-sustaining treatment prior to cardiac arrest and resulted in the resident's death during transport. This was evident for one (Resident #200) of one resident reviewed for an unexpected death during a complaint survey. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2026

  Based on observation, record review, and interview with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the kitchen tour of the recertification survey. The findings include: A food-contact surface refers to any surface of equipment and utensils that typically comes into contact with food; or from which food may drain, drip, or splash onto food; or a surface that is usually in contact with food. […]

• No harm, potential for more than minimal, widespreadF880Mar 6, 2026

  Based on observation and interviews, it was determined that the facility failed to ensure staff performed hand hygiene when entering and exiting a room in which a resident was on neutropenic precautions. This was evident for 1 (Resident #84) of 1 resident on neutropenic precautions reviewed during the initial screening process of the annual survey.The findings include:Neutropenic precautions are critical safety measures for individuals with low white blood cell counts (neutropenia) to prevent life-threatening infections. […]

• No harm, potential for more than minimal, patternF584Dec 20, 2024

  Based on observation and interview it was determined the facility failed to ensure bathroom and floor tiles were maintained in good repair and that the exhaust ventilation system was working. This was found to be evident on 4 out of 4 units observed during the survey. The findings include: 1) Tour of the first-floor bathrooms/shower room secondary to reported complaints of cleanliness revealed substantiated concerns related to a sanitary environment for Residents to bathe. Tour initiated on 12/18/24 at 9:32 AM of the Antietam shower room revealed hair on both shower stall walls, a caked white substance on the wooden seats, the molding along the entrance into both shower stalls was missing or peeling off. There was noted black areas where the molding was missing. […]

• No harm, potential for more than minimal, patternF609Dec 20, 2024

  Based on review of medical records, facility policies, investigation documentation, and interviews, it was determined the facility failed to ensure that allegations involving abuse were reported to the State Agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident for 5 (Resident #421, #214, #468, #469, #264) of 13 residents reviewed for abuse allegations. The findings include: 1) a. Review of a complaint from 2/1/23 on 12/19/24 at 11:51 AM revealed that resident's family member was notified by the facility that Resident #421 had a fall from [resident] shoes and was sent to the emergency room where a cat scan was completed. […]