South Mountain Restoration Cen

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Sep 18, 2025

  Based on facility policy and document review, observations, and staff interviews, it was determined that the facility failed to utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Findings include:Review of facility policy, titled Operation, Cleaning, and Maintenance of the Dishwasher, last revised March 18, 2024, read, in part, Check thermometers for proper temperatures, wash should register 150 F (Fahrenheit- unit of measure). The machine will be shut down, and Maintenance will be notified when the required temperatures are not achieved. […]

• No harm, potential for more than minimal, patternF812Oct 3, 2024

  Based on facility policy review, observations, facility documents review, and staff interviews, it was determined that the facility failed to store food/beverages and utilize equipment in accordance with professional standards for food service safety in the kitchen and in three of three nourishment refrigerators; and failed to serve food in a sanitary manner during one of two tray line observations. Findings include: Review of facility policy, titled Refrigeration and Storage Procedures, with a last revised date of December 6, 2023, revealed, in part, Receiving Guidelines D. All food items will be stored with labels or markings designating: 1. Content; 2. Received Date; 3 Either a) manufacturer information (date/lot) or b) relevant disposal dates; E. […]

• No harm, potential for more than minimal, patternF812Dec 7, 2023

  Based on observation, review of facility policy, and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food safety in the main kitchen and in one of two nourishment refrigerators. Findings include: Review of facility policy, titled Refrigeration and Storage Procedures, with last review date of October 5, 2021, revealed the following: 9135.13 Receiving guidelines C. All items will be dated with the received date and rotated in refrigerator/freezer to ensure First In/First Out and in subsection, titled The following rules for dry storage will apply in the Dietary Department and in the Storeroom, indicated, in part, at 9135.15 All items will be dated upon receiving. […]

• No harm, potential for more than minimal, patternF868Dec 7, 2023

  Based on review of facility documents, facility policy review, and staff interview, it was determined that the facility failed to ensure that all required committee members attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters reviewed (December 2022- February 2023). Findings include: Review of facility's Quality Assurance and Performance Improvement Program, last reviewed March 21, 2023, indicated the QAPI Committee is composed of at least the following individuals: QAPI Director (Chairperson) QAPI Specialist Chief Executive Officer QAPI Coordinator Medical Director RN Assessment Coordinator Chief Operating Officer Chief Social & Rehab Executive Infection Control Preventionist Director of Nursing A review of Quality… […]

• No harm, potential for more than minimal, patternF657Dec 14, 2022

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of two residents reviewed for pressure ulcers (Residents 20 and 55). Findings include: Review of Resident 20's clinical record revealed diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and muscle weakness. Review of Resident 20's active care plan revealed that he currently had a pressure ulcer on his sacral area. Review of Resident 20's current physician orders failed to reveal any treatment orders for an active, open wound on his sacrum. […]