Inspection Reports for
Mountain Manor

The facility failed to ensure proper care and treatment in accordance with professional standards for Resident 1 by not clarifying the physician's IV bolus order, incomplete documentation of IV therapy details by licensed nurses, and lack of timely pharmacy follow-up for IV supplies. These deficiencies posed potential risks for fluid hydration treatment not being met and possible adverse events.

The facility was found deficient in ensuring proper monitoring of a resident's alarm bracelet for wandering risk, timely administration of insulin medication, and adherence to infection prevention protocols including proper sanitization of shared glucometers and use of personal protective equipment during resident care.

The visit was triggered by a complaint regarding an absent without leave incident involving resident R1. The complaint was substantiated as the resident left unassisted contrary to medical restrictions.

The investigation found that resident R1 left the facility unassisted on 05/11/2025 despite a physician's report indicating R1 was unable to leave unassisted, posing an immediate health and safety risk. The facility increased safety checks following the incident and was cited for deficiencies related to insufficient staffing to ensure resident care and supervision.

The facility was found deficient in multiple areas including failure to maintain a comfortable noise level for residents, inadequate bed hold notifications, incomplete care plans, medication administration errors, communication barriers, respiratory care inconsistencies, pharmaceutical service deficiencies, medication labeling and storage issues, food service personnel competency, menu adherence, food safety and sanitation, quality assurance committee composition, infection prevention and control practices, and antibiotic stewardship.

The complaint investigation found that Resident 1 eloped from the facility unattended, fell outside, and complained of neck and left knee pain. The resident was assessed and transferred to the ER. The facility's policy on elopement lacked preventive interventions. The Administrator confirmed the incident and noted no prior elopement attempts by the resident.

The facility failed to prevent elopement for one resident who wandered outside the facility and fell, resulting in neck and knee pain. The resident had a history of falls and cognitive impairment. The facility's elopement policy did not include interventions to prevent such incidents.

The complaint investigation found that Resident 3 was moved without advance notice or consent, violating his rights. The Social Service Director confirmed no consent form was used and no documentation of notice or explanation was present. The room change was discussed only during the morning IDT meeting on the day of the move.

The facility failed to ensure Resident 3's rights were exercised when he was moved to another room without advance notice or consent, resulting in confusion for the resident. Documentation showed no evidence of written or verbal notice, explanation for the move, or consent from Resident 3.

The facility was found deficient in multiple areas including delayed completion of admission assessments, incomplete care plans, medication errors, improper medication storage, failure to follow dietary menus, inadequate infection control practices, and food safety violations. Most deficiencies were assessed as minimal harm or potential for actual harm.

The visit was complaint-related due to an absent without leave incident involving resident R1. The complaint was substantiated by findings that R1 left the facility unassisted against medical advice.

The investigation found that resident R1 was observed leaving the facility unassisted despite a physician's report indicating R1 was unable to leave unassisted, posing an immediate health and safety risk. Deficiencies were cited related to insufficient staffing to ensure resident supervision.

The facility failed to ensure that one of three sampled residents (Resident 39) was informed about a new medication (a diuretic) added to their treatment without proper education. This failure potentially deprived the resident of the right to make informed decisions regarding their care.

The facility was found deficient in multiple areas including failure to maintain resident dignity during meal assistance, inadequate resident education on medication changes, incomplete and inaccurate resident assessments and care plans, improper medication administration practices, failure to complete annual performance reviews for nursing assistants, medication storage and accountability issues, infection control lapses, and food preparation and storage deficiencies.

The complaint investigation found that Resident 3 physically abused Resident 4, causing injuries that required hospital treatment. The local Sheriff's Department took Resident 3 into custody for felony elderly abuse. The facility acknowledged it was not equipped to care for residents with aggressive behaviors and failed to document Resident 3's agitation episodes properly.

The facility failed to protect two residents from physical abuse when Resident 3 struck Resident 4, resulting in Resident 4's transfer to the Emergency Department for facial injuries and Resident 3 being taken into police custody. The facility also failed to provide adequate care for Resident 3's combative behaviors and did not properly monitor his agitation as required by policy.

The complaint investigation was substantiated for inadequate record keeping after evidence showed mix-ups in resident mail and billing errors. Other allegations including medication errors, safeguarding personal belongings, admission agreement violations, overcharging, and telephone responsiveness were found unsubstantiated.

The investigation substantiated the allegation of inadequate record keeping related to resident mail and billing errors. All other allegations, including inappropriate medication administration, failure to safeguard personal belongings, non-compliance with admission agreement, overcharging for unauthorized services, and telephone issues, were found to be unsubstantiated.