Mountain Manor Senior Residence

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards for one of three sampled residents (Resident 1) when Resident 1's metoprolol (blood pressure medication) was not administered according to physician orders. This failure had the potential to result in dizziness, fainting, and/or a fall for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment in accordance with the professional standards of practice were provided to Resident 1, when: 1. The Physician's Order (PO) for one time IV (intravenous, into the vein) 150 bolus (single, relatively large dose administered over a short period of time) was not clarified to specify the infusion duration; 2. The Licensed nurses (LNs) did not thoroughly document all aspects of the IV therapy, including the date and time of insertion, IV catheter gauge, IV site assessment results and patient response; 3. The LNs did not thoroughly document what time the MD order was faxed to the pharmacy and whether the order was received by the pharmacy to ensure timely delivery of IV supplies; and4. The LN did not document the start time and the end time of the IV bags administered including the IV bolus administration. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of five sampled residents (Resident 3) received treatment and care in accordance with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 3's alarm bracelet was not monitored for placement and functionality. This failure had the potential for an ineffective wandering management of Resident 3 and risk for Resident 3's further elopement occurrences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of five sampled residents (Resident 1) was free from significant medication error when Resident 1 did not receive prescribed insulin (medication used to manage blood sugar level) in accordance with the physician's order. This failure has the potential to result in Resident 1 experiencing hypoglycemia (too low blood sugar level) and other unnecessary insulin side effects which could negatively affect Resident 1's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 61 residents when:1. A shared glucometer (a device which measures blood sugar using blood from the fingertip) was not sanitized properly after use; and,2. A facility staff did not wear required personal protective equipment (PPE) when performing resident care on Resident 4 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use) and there was no EBP signage posted outside of Resident 4's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety, when: 1. The ice machine was not clean; 2. The blade of the can opener was not well maintained; 3. Significant scratches were found on the cooking surfaces on the nonstick cooking pans with coating; 4. Significant amount of food items were found with inconsistent dating practices in the reach-in refrigerators, dry storage and walk-in freezer; 5. Opened food packages were found not resealed properly; 6. The thawing meat was found with no pull date to indicate when the meat thawing started; 7. Produce food items were found not fresh; and 8. The resident's food refrigerator was found with two issues: a. The freezer section was not clean; and b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted on the medication administration record (MAR) and the Controlled Drug Record (CDR) for two of four randomly selected residents (Resident 24 and Resident 197); 2. Controlled drug shift-to-shift count records (a record used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were routinely signed by the off-going and on-coming nursing shifts; and 3. Removal of narcotic medication from the emergency kit (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was accurately and completely documented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Multi-dose medications were dated with an open and discard date to confirm they were not used beyond the discard date; 2. Prescription medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; 3. Medications with different routes of administration were stored in accordance with facility policy and procedures (P&P); and 4. Expired medications were not available for resident use. These failures increased the residents' potential to unsafely receive inadequately labeled medications with reduced potency, past their discard date, and through the wrong route of administration for a census of 45 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services, when Dietary Aide (DA) 1 and DA 2 were unable to verbalize the process of manual dishwashing by using two-compartment sinks correctly. This failure had the potential to place 45 out of 45 highly susceptible residents who received food from the kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meals on 4/21/25 and 4/22/25, when: A. During a dining observation on 4/21/25: 1. Three residents (Residents 11, 21 and 35) on Consistent Carbohydrate (CCHO) diet (a therapeutic diet to manage diabetic disease and/or to stabilize blood sugar level) got pineapple Bavarian cream square instead of pineapple tidbits as listed on menu; and 2. Resident 17 with CCHO diet received pudding instead of CCHO dessert. B. During a meal service distribution on 4/22/25: 1. [...]

Inspectors wroteA review of Resident 147's admission Record, indicated Resident 147 was admitted to the facility in 2025 with diagnoses including right leg cellulitis and right ankle and foot osteomyelitis (a bone infection characterized by inflammation of the bone tissue). A review of Resident 147's OSR, dated 4/23/25, indicated Resident 147 had an open wound dressing on the right arm, left wrist, and left front arm, a surgical site to right foot, and wound care to bilateral feet. During a concurrent observation and interview on 4/22/25 at 8:23 a.m. with CNA 6, CNA 6 confirmed and stated there were no EBPs signage or PPEs placed by Resident 147's room. During a concurrent observation and interview on 4/23/25 at 8:39 a.m. with LN 6, LN 6 confirmed there was no EBP signage or PPE cart available in front of Resident 147's room. During an interview on 4/24/25 at 9:42 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable noise level for four residents (Resident 299, Resident 38, Resident 1, and Resident 300) of a census of 45. This failure decreased the facility's potential to maintain the residents' comfort level and sleep.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notification upon transfer to hospital to one of 17 sampled residents (Resident 36), when Resident 36 was transferred to hospital without a bed hold notification on 3/4/25, 3/11/25, and 4/15/25. This failure decreased the facility's potential to protect Resident 36's right in bed hold and return to facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of 17 sampled residents (Resident 397), when the care plan did not address Resident 397's insomnia (trouble falling asleep or staying asleep) and trazodone (a medication to treat insomnia). This failure decreased Resident 397's potential to receive appropriate care, services, and treatment.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for one of 17 sampled residents (Resident 397), when Resident 397 sustained a bruise (an injury or mark where the skin has not been broken but is darker in color, often as a result of being hit by something) to the right cheek. This failure decreased the facility's potential to provide Resident 397 with a person-centered care plan that meets the changed care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of 17 sampled residents (Resident 196), when Licensed Nurse 2 (LN 2) did not clarify a physician's order with multiple dosages prior to administering medication. This failure had the potential to result in Resident 196 not receiving the correct dosage of medication and worsening of their clinical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the plan of care for one of 17 sampled residents (Resident 247), when Resident 247's communication board was not available for use during provision of care. This failure decreased the facility's potential to meet Resident 247's ability to communicate her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services according to professional standards of quality for one of 17 sampled residents (Resident 24), when Resident 24's administered oxygen was not consistent with the physician's order. This failure decreased the facility's potential to follow the physician's order when providing respiratory services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee was composed of the required committee members for a census of 45 residents. This failure decreased the facility's potential to identify, monitor, implement and enhance the quality of care for residents.

Inspectors wroteBased on interview and record review, the facility failed to follow the Antibiotic Stewardship Program for one of 17 sampled residents (Resident 247), when Resident 247 was prescribed an antibiotic without adequate clinical and laboratory findings for its use. This failure increased Resident 247's potential for an unnecessary administration of an antibiotic without appropriate indication.

Inspectors wroteBased on interview and record review, the facility failed to prevent elopement for one of 3 sampled residents (Resident 1 ) when he left the facility unaccompanied by staff. This failure resulted in Resident 1 sustaining a fall, complained of neck and left knee pain and, verbalized he hit his head.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled resident's (Resident 3's) rights were exercised when the resident was moved to another room without advance notice. This failure resulted in a violation of Resident 3's rights and left the resident confused.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. The ice machine was not clean with black and pink substances at the bottom of the ice evaporator unit (a part where water freezes to produce ice and push out from the unit) and pink slimy substances on the water curtain (a plastic cover rests over the ice evaporator where the ice dispenses); 2. There were 11 out 15 tomatoes with black and white indented spots found in dry storage; 3. There were several metal pans found stacked wet and contained food debris when stored at the clean and ready-to-use storage areas; 4. Employee's personal belonging found in the dry food storage area; and, 5. Juice dispenser was not clean with significant dust on the vent where juice dispended.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 38 when two opened Emergency drug kits found in the medication room had not been replaced by the pharmacy according to the facility policy. This failure had the potential for residents not receiving necessary medications on time or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two of 10 sampled residents (Resident 241 and Resident 540) when: 1. For Resident 241, a licensed nurse administered famotidine, a medication used to treat heartburn and stomach acid reflux, not in accordance with Physician Orders. 2. For Resident 540, metoprolol succinate, a medication used to treat high blood pressure, was not available for the resident. As a result, 2 errors were identified out of 37 opportunities for error during the observation of medication administration; the facility medication error was 5.41%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored correctly, when: 1. Six metered-dose inhalers were found with unlabeled open dates in Medication Cart A; 2. Two expired insulin vials were found in the medication refrigerator; 3. Prescription medication blister packs were found lodged in the rear gap of Medication Cart A; 4. Two expired glucometer control solutions were found in Medication Cart A; and, 5. Loose pills were found in Medication Cart A. These failures had the potential for omitting medications, medication misuse, and administering or using ineffective expired pharmaceutical products.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic diet menu was followed for the census of 38 during the lunch service on 6/4/2024 when: 1. Four residents (Resident 1, 5, 25, and 491) with (CCHO consistent carbohydrate) diet (a diet used in the treatment for diabetes) received one serving of fruit mix crumble cake instead of half serving for dessert; 2. One resident (Resident 2) with small portion diet, received one serving of fruit mix crumble cake instead of half serving for dessert; and, 3. One resident (Resident 5) with mechanical soft texture (a texture-modified diet that restricts foods that are difficult to chew or swallow) diet, received chopped salad with croutons instead of without croutons. These failures had the potential to result in compromising the medical and nutrition status of those five residents.

Inspectors wroteBased on interview and record review, the facility failed to complete the Minimum Data Set (MDS, an assessment tool used to guide care) admission Assessment within 14 calendar days after admission for two in a census of 38 (Resident 9 and Resident 21). This failure had the potential to delay care planning and the delivery of care that would have been identified in the admission assessment.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of 15 sampled residents (Resident 491), when the care plan did not address Resident 491's dialysis (a procedure to remove waste products from the blood when the kidneys stop working properly) care and interventions. This failure decreased the facility's potential to address the residents' individualized and specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality of care for one of 15 sampled residents (Resident 290) when Resident 290 was allowed to wear a left leg/knee immobilizer without a physician's order. This failure resulted in Resident 290's use of a leg/knee immobilizer without a required physician's order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain nail care for one of 15 sampled residents (Resident 25) when, Resident 25's fingernails on both hands were long and packed with a brownish-black substance. This failure decreased the facility's potential to maintain residents' nail care and prevent infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 2) received care in accordance with professional standards when Resident 2's physician order to float heels when in bed was not implemented. This failure decreased the facility's potential to prevent skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 sampled residents (Resident 15) had access to vision services when Resident 15 was not assisted in obtaining prescription eyeglasses. This failure resulted in Resident 15 not having eyeglasses to maintain good vision.

Inspectors wroteBased on interview and record review the facility failed to ensure two of 15 sampled residents (Resident 2 and Resident 3) were free from unnecessary medication when: 1. Resident 2's anti-anxiety medication (a medication used to help reduce symptoms of worry, fear, and panic) was prescribed without a stop date; and, 2. Resident 3's use of an antibiotic medication (medicines that treat bacterial infections in humans) was continued without adequate indication. These failures increased the risk of Resident 2 and Resident 3 to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for one of 15 sampled residents (Resident 32) when the Certified Nursing Assistant 3 (CNA 3) did not apply a face shield (a device to protect the eyes and face) while assisting Resident 32 with meal in the Coronavirus-19 Disease (COVID-19, an infectious disease caused respiratory illness) unit. This failure had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted on a daily basis at the beginning of each shift for a census of 38, when staffing information was not posted on weekend and at the beginning of weekdays' morning shifts. This failure decreased the facility's potential to post staffing information on a daily basis for residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to complete the annual performance reviews for eight of eight sampled certified nursing assistants (CNAs; CNA 1, CNA 2, CNA 3, CNA 4, CNA 5, CNA 6, CNA 7, and CNA 8). This failure increased the residents' potential to receive poor quality of care from CNAs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were followed when: 1. Insulin (a hormone that works by lowering levels of glucose-sugar in the blood) was injected into the muscle instead of into fatty tissue for Resident 149; and, 2. The pharmacy auxiliary sticker label (a label added on to a dispensed medication package by a pharmacist that displays additional warnings, information, or instructions) was not followed by nursing staff during medication administration for Resident 14. These failures had the potential for residents to have dangerous blood glucose levels and more painful injections, and medications to not be absorbed properly due to their properties being altered from not being administered correctly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), availability of emergency drugs, and develop and implement procedures to ensure safe handling of hazardous drugs (medications capable of causing serious effects) when: 1. Random controlled medication use audits for 1 out of 3 residents (Resident 44) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the resident; 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure irregularities were identified during the medication regimen reviews for three of 12 sampled residents (Resident 3, Resident 5 and Resident 9) when: 1. Resident 3 had an order for a PRN (as needed) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) with no end date; 2. Resident 5 had an order for two PRN psychotropic medications with no end date and no indication for haloperidol lactate (a medication used to treat schizophrenia [a serious mental disorder in which people interpret reality abnormally]); and 3. Resident 9's indication for clonazepam (a medication used to treat seizures, panic disorders and anxiety) was incorrect. These failures had the potential for undetected medication irregularities or residents to receive unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of 12 sampled residents (Resident 3, Resident 5, Resident 9 and Resident 14) did not receive psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) unnecessarily when: 1. Resident 3 had an order for a PRN (as needed) psychotropic medication with no end date; 2. Resident 5 did not have a signed consent or behavior monitoring for psychotropic medication use; 3. Resident 9's indication for clonazepam (a medication used to treat seizures, panic disorders and anxiety) was incorrect and there was no behavior and side effects monitoring; and 4. Resident 14's hydroxyzine (medication used to treat anxiety and allergies) order did not have an indication, there was no behavior monitoring and no signed consent for the medication in the resident's record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Opened biologicals and multi-dose inhalers were dated with an open and discard date, to ensure they were not used beyond the discard date; and expired and discontinued medications were not available for resident use; 2. Medications were not left unattended on top of medication carts, and carts were kept securely locked when left unattended; and 3. Monitor and record temperatures for the Medication Storage Room Refrigerator used to store medications and vaccine. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date or improper storage, and diversion or misuse of medications from not being securely stored in medication carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when nursing staff did not perform hand hygiene during direct resident care and glucometers were not sanitized and disinfected in accordance with facility policy and procedure (P&P) and manufacturer's specifications after resident use. These failures had the potential to expose residents to infectious disease and result in the development of infection and transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 12 sampled resident's (Resident 17) dignity was maintained when staff was observed standing in front of the resident while assisting him with his meal. This failure had the potential to negatively impact Resident 17's dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 39) was informed of changes in their treatment when a new medication was added without education. This failure had the potential to deprive the resident of the right to make decisions regarding care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST) for one resident (Resident 22) of 12 sampled residents was valid in the electronic health record (EHR). This failure had the potential for Resident 22's POLST not to be followed in the event of medical emergency.

Inspectors wroteBased on interview and record review, the facility failed to comprehensively reassess one of 12 sampled residents (Resident 7) when Resident 7's skin tear deteriorated to a pressure injury (injury to the skin and underlying tissue resulting from prolonged pressure on the skin). This failure had the potential to result in Resident 7 having unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess two of 12 sampled residents (Resident 10 and Resident 22) when: 1. Resident 10's MDS, dated [DATE], indicated she had recently had pneumonia (infection in the lungs); and 2. MDS did not accurately reflect Resident 22's functional status. These failures decreased the facility's potential to identify residents' care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure a baseline care plan was accurately developed and signed within 48 hours for one of 12 sampled residents (Resident 250). This failure had the potential for Resident 250 to not receive person-centered care.

Inspectors wroteBased on interview, and record review the facility failed to develop and complete a comprehensive person-centered care plan for two out 12 sampled residents (Resident 42 and Resident 99). These failures had the potential for Resident 42 and Resident 99 to not receive appropriate care, services, and treatment.

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan for one resident (Resident 22) of 12 sampled residents, when Resident 22's restorative nursing (RNA) program intervention was not quarterly revised and evaluated for effectiveness. This failure decreased the facility's potential to provide a person-centered care plan that meets the residents' needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure menus were followed for a census of 46 when staff prepared pureed rice without referring to the recipe. This failure had the potential to alter the taste and nutritive value of the food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dry bulk goods were stored safely for a census of 46 when a bag of older flour was placed inside a bag of new flour and mislabeled. This failure had the potential to cross-contaminate the flour and lead to foodborne illnesses.