Hibriten Mountain Nursing and Rehabilitation

Inspectors wroteBased on record review and staff and Consultant Pharmacist interviews, the facility failed to have a system in place to ensure an accurate account of 1 of 1 resident's controlled medications (Resident #98), failed to have effective systems in place to ensure 2 of 2 residents (Resident #53 and Resident #74) had their physician prescribed narcotic pain medication available for administration, and the facility also failed to have a system to maintain an accurate receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled drugs for 5 of 5 months. The deficient practice occurred for 3 of 4 residents reviewed for misappropriation of medications.

Inspectors wroteBased on observations, record reviews, staff and resident interviews, the facility failed to assess Resident #62 for the ability to self-administer medications for 1 of 1 resident reviewed for self-administering medications.

Inspectors wroteBased on observation, record reviews, family, and staff interviews, the facility failed to complete a Do Not Resuscitate (DNR) form (a DNR form is a legal document signed by the physician) for a resident with a DNR physician order (Resident #11) at admission. The facility also failed to ensure resident advanced directive information was consistent throughout the medical record (Resident #31 and Resident #62). This deficient practice occurred for 3 of 6 residents reviewed for advanced directives.

Inspectors wroteBased on record review, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of resident narcotic medications for 1 of 4 resident reviewed for misappropriation of resident property (Resident #62).

Inspectors wroteBased on record reviews, resident and staff interviews, and Psychiatric Nurse Practitioner (NP) the facility failed to refer one resident with a new mental health diagnosis for Preadmission Screening and Resident Review (PASRR) level II for 1 of 1 resident for PASRR (Resident #31).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan for 1 of 6 residents whose comprehensive care plans were reviewed (Resident #63).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a care plan in the area of urinary catheter for 1 of 3 residents reviewed for care plans (Resident #99).

Inspectors wroteBased on observations, record review, family member, and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 1 resident reviewed for foot care (Resident #63).

Inspectors wroteBased on observations, record reviews, manufacturer's instructions, and staff and Consultant Pharmacist interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 4 medication errors out of 26 opportunities, resulting in a medication error rate of 15.38% for 2 of 3 residents observed during the medication administration (Resident #4 and Resident #85).

Inspectors wroteBased on manufacturer guidelines, observations and staff interviews, the facility failed to label DuoNeb solution (inhalation breathing solution) with an open date for 1 of 3 medication carts (C and D medication cart) reviewed for medication storage.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow their Infection Control policy and Hand Hygiene policy when Nurse Aide #1 did not perform hand hygiene before applying clean gloves and Nurse Aide #1 nor the Unit Manager applied gowns while providing suprapubic catheter care on Resident #26. This deficient practice occurred for 2 of 7 staff members observed for infection control practices (Nurse Aide #1 and Nurse #4).

Inspectors wroteBased on record review, observations, and interviews with the resident's responsible party, staff, and the Medical Director, the facility failed to supervise a severely cognitively impaired resident who demonstrated wandering behaviors in the facility and prevent him from entering into an unlocked kitchen door and then exiting the facility through the kitchen's exterior door for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 who had a diagnosis of dementia exited from the facility without staff's knowledge for an undetermined length of time on the evening of 7/11/25 and was observed by staff through the door at the end of C hall standing by the facility's transport van parked outside the facility in the back parking lot in socked feet. [...]

Inspectors wroteBased on record review and interviews with the resident's responsible party and staff, the facility failed to notify the responsible party of elopement for 1 of 3 residents reviewed for notification of change (Resident # 1).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to protect a resident's right to be free from abuse when Resident #4 attacked Resident #5 which resulted in cuts above the right eye, bruising around the nose, and bleeding from his gums and required an emergency room visit. This was for 1 of 3 residents reviewed for resident-to-resident abuse (Resident #4).

Inspectors wroteBased on record review, observations and interviews with staff and the Medical Director, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of a wrong dosage and failure to have the resident rinse their mouth after being given a steroid inhaler (2 medication errors out of 31 opportunities), resulting in a medication error rate of 6.45% for 2 of 4 residents observed during medication pass (Resident #2 and Resident #3).

Inspectors wroteBased on record review, and resident, staff, and detective interviews, the facility failed to protect the resident's (Resident #70) right to be free from misappropriation of property when Housekeeper #1 used Resident #70's debit card to set up a mobile payment application account on his [Housekeeper #1's] phone without Resident #70's permission or knowledge. Housekeeper #1 was alleged to have sent approximately $4,000.00 of unauthorized payments from Resident #70's bank account to his mobile payment application account from February 2024 to May 2024. Resident #70 stated, I am poor and he took everything I had. He indicated he was very upset that someone he trusted had taken advantage of him and he was worried to death over the loss of money and the potential for identity theft. [...]

Inspectors wroteBased on record review, and staff and Adult Protective Services (APS) Intake Social Worker interviews, the facility failed to file a report with the state agency no later than 24 hours after becoming aware of an allegation of misappropriation of resident property and failed to report the incident to APS for 1 of 3 residents reviewed for abuse (Resident #70).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 2 residents reviewed for bladder continence (Resident #74 and Resident #35).

Inspectors wroteBased on record review and staff interviews, the facility failed to update a resident's care plan after she ingested wound cleanser for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #8).

Inspectors wroteBased on record review, and resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to ensure the correct medications were administered to the correct resident for 1 of 5 residents reviewed for unnecessary medications (Resident #80).

Inspectors wroteBased on observations, record reviews, and staff, Resident, Wound Nurse and Medical Director interviews, the facility failed to provide care in a safe manner when a dependent resident (Resident #57) fell off the bed during incontinence care. The facility also failed to provide an environment free from a potential hazard when wound cleanser was left unattended on top of the treatment cart and an unmeasurable amount was ingested by Resident #8. This was for 2 of 4 residents reviewed for accidents.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to obtain an order for the use of supplemental oxygen and post oxygen cautionary signage for 1 of 1 resident (Resident #75) reviewed for respiratory care.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to develop a comprehensive, individualized, and person-centered care plan in the area of behavior for 1 of 2 residents reviewed for behaviors (Resident #37).

Inspectors wroteBased on record review and staff interviews, the facility failed to allow a resident with behaviors to remain in the facility and to provide written documentation which stated the reason the facility could not meet the residents needs for 1 of 3 resident (Resident #6) reviewed for transfer and discharge.

Inspectors wroteBased on record review, Hospice staff, Hospital Nurse Practitioner, and staff interviews, the facility failed to allow resident to return to the facility after being sent to the hospital for a medical evaluation using the residents' behaviors prior to discharge as a basis for their decision for 1 of 3 residents reviewed for transfer and discharge (Residents #6).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide incontinence care to a resident prior to her wetting through her brief and her pants for 1 of 3 residents (Resident #4) reviewed for activities of daily living (ADL).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to follow their Infection Control Policy for Enhanced Barrier Precautions (EBP), when the Wound Nurse failed to wear a gown while providing wound care to 2 of 3 residents (Resident #2 and Resident #3) reviewed for infection control.

Inspectors wroteBased on observations, record reviews, resident, family and staff interviews, the facility failed to provide hair care to a dependent resident for 1 of 3 residents reviewed for activities of daily living (Resident #1). Resident #1 was observed with matted hair while waiting to go for an outside Physician appointment. Resident #1 stated the matted hair was painful and she felt like the staff did not care.

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey dated 9/08/23. This was for two repeat deficiencies that were cited in the areas of self-determination, activities of daily living care provided for dependent residents that were originally cited during a recertification and complaint survey dated 03/21/23, 09/08/23 and subsequently recited during the onsite revisit and complaint survey dated 10/24/23. The area of food procurement was originally cited during a recertification and complaint survey dated 09/08/23 and subsequently recited during the onsite revisit and complaint survey dated 10/24/23. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to date opened items stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to ensure a resident had been assessed to self-administer over the counter medications located in a residen'st room. This occurred for 1 out of 3 residents reviewed for medication administration (Resident #3).

Inspectors wroteBased on observations, record review, resident and staff interview the facility failed to honor resident requests for two showers per week for 2 of 4 residents reviewed for choices (Resident #2 and Resident #4).

Inspectors wrote4a. Resident #64 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, anxiety, depression and fibromyalgia. The care plan dated 06/15/22 revealed Resident #64 had a self-care deficit. The goal the Resident would improve in her current level of function in her activities of daily living (ADL) would be attained by utilizing interventions such as: providing a sponge bath when a full bed bath or showers cannot be provided. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64's cognition was moderately intact and had no behaviors of rejection of care. The MDS indicated the Resident required extensive assistance of two staff for transfers, personal hygiene and dressing. The MDS also indicated the Resident was incontinent of bladder and bowel. [...]

Inspectors wrote4. Resident #57 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, dementia without behaviors, major depressive disorder and history of stroke. A review of Resident #57's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #57 to be cognitively intact with no psychosis, behaviors, rejection of care, or instances of wandering. Resident #57 was coded as receiving antipsychotics 1 of 7 days during the lookback period but was coded as not receiving antipsychotics since her admission or entry to the facility or since the prior Minimum Data Set assessment. A review of Resident #57's physician orders revealed no current, completed, or discontinued orders for the use of an antipsychotic. A review of Resident #57's August Medication Administration record revealed no antipsychotics were provided to Resident #57 in the Month of August. [...]

Inspectors wroteBased on observations, record reviews and staff interviews the facility failed to provide sufficient nursing staff resulting in residents not having their choices honored for receiving two showers a week, failed to honor a resident's request to get out of bed and the facility failed to provide nail care for 5 of 5 residents reviewed (Resident #36, #23, #39, #60, and #64) for choices and activities of daily living.

Inspectors wroteBased on record reviews and Director of Nursing (DON) interview the facility failed to ensure the DON for the Skilled Nursing Facility worked full time as the DON of the facility. The DON served as a charge nurse having a resident care assignment that included working on the medication cart with a facility census of greater than 60 residents for 8 of 8 days reviewed for sufficient nurse staffing. 07/24/23, 07/25/23, 08/09/23, 08/10/23, 08/14/23, 08/29/23, 08/30/23 and 08/31/23.

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date leftover food items available for resident consumption stored in 1 of 1 reach in refrigerator and failed to date pre-filled bowls of cereal stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey dated 3/21/22. This was for six repeat deficiencies that were cited in the areas of self-determination, accuracy of assessment, care plan timing and revision, activities of daily living care provided for dependent residents, sufficient nursing staffing, and label and storage of drugs and biologicals that were originally cited during a recertification and complaint survey dated 3/21/22 and subsequently recited during the recertification and complaint survey dated 9/8/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteed on record review, family, staff, and Nurse Practitioner interviews the facility failed to change Resident #82's advance directive (code status) as directed by his power of attorney (POA) for 1 of 1 resident reviewed for advance directives.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan within 7 days of the completion of a resident's admission Minimum Data Set assessment (Resident #83) for 1 of 2 residents reviewed for discharge.

Inspectors wroteBased on record review, resident, and staff interviews the facility failed to invite 2 of 2 residents to a care plan meeting (Resident #39 and Resident #60) that were reviewed for care plans.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living (Resident #36).

Inspectors wroteBased on observations, record review, resident, and staff interviews the facility failed to ensure that oxygen was delivered at the prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #13).

Inspectors wroteBased on record reviews and interviews with residents, staff, Pharmacist and Nurse Practitioner (NP #1), the facility failed to acquire medications ordered for administration which resulted in 2 missed doses of the controlled substance medication prescribed for pain for 1 of 2 residents reviewed for the provision of pharmaceutical services (Resident #289).

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to discard expired medications and failed to store a controlled substance in a permanently affixed compartment in the refrigerator in 1 of 1 medication room (main medication room) for review of medication storage.

Inspectors wroteBased on observations and interviews the facility failed to change a soiled privacy curtain for 1 of 8 rooms on E hall (room [ROOM NUMBER]) reviewed for homelike environment.