Mountain Home Health Services

Staff interviews the Registered Nurse failed to practice proper hand hygiene/correct bag technique for 1 of 3 patients who received a joint visit to observe wound care [# 6 ]. The findings included: The policy, Hand Hygiene Policy and Compliance Program [7/2021], was received by RN # 2 on 9/15/25…

Staff interviews the Registered Nurse failed to provide privacy for the patient during wound care for 1 of 3 patients who received a joint visit [#10]. The findings included: The policy, Patient Bill of Rights and Responsibilities [2/22], was provided by RN # 2 on 9/16/25 at approximately 3:30 pm.

Base on agency policy, direct observation, clinical review, and interviews with staff and patients/caregivers, the Plan of Care [POC] failed to include all the current/correct medications the patient was taking for 4 of 5 patients who received a home visits [#6,7,8, and 10]. The findings included…

Staff interviews the agency failed to follow the physician's order on the Plan of Care [POC] related to reporting vital signs outside of the given parameters for 3 of 19 records reviewed [#10, 2, 13, and 16]; and failed to follow the physician's order for foley catheter size for 1 of 2 charts…

Staff interviews the Registered Nurse failed to document a wound assessment with each nursing visit when wound care was preformed for 5 of 6 patients with a wound [#6, 8, 10, 11, and 12]; and the Registered Nurse copied and pasted nursing notes for 1 of 19 charts reviewed [#9]. The findings…

The agency failed to provide aide supervisory visits at least every 14 days for 2 of 3 patients who received aide services [#13 and 17]. The findings included: 1. Patient # 13 had a Start of Care date of 5/1/525 with an admitting diagnosis of hemiplegia and hemiparesis [paralyzed and weakness on…

The agency failed to conduct wound assessments for 3 of 10 patients with wounds (#13, 16, 21 and #8); and to accurately assess vision for 1 of 24 patients (#24); failed to obtain PICC line [ Peripheral inserted central catheter] and arm circumference measurements for 1 of 1 patient [#8] with a PICC…

The agency failed to clarify medication doses for 1 of 1 patients [#6] that had routine medications with a varying dose.

Staff interviews the Plan of Care [POC] failed to include all required components for 2 of 24 patients [#15 and 24]. The findings included: 1. Patient #15 was admitted on 6/29/22 with a diagnosis of neuromuscular dysfunction of the bladder (a condition where the nerves and the muscles of the…

Staff interviews the agency failed to use the correct volume of saline flush after a blood draw for 1 of 1 patients [#8] with a PICC [Peripherally inserted central catheter]. The findings included: The policy/procedure “Plan of Care” with effective date of 9/15/2022 stated, “care and services…

Staff interviews there was no evidence the agency notified the physician of an oxygen saturation out of parameters for 1 of 1[#10] on oxygen; of a change in patients condition for 1 of 1 [#6] that were jaundice; and failed to notify the physician of a full urinary system assessment for 1 of 1…

The agency failed to follow the Plan of Care for obtaining weight for 2 of 2 patients with weights ordered (#13 and #8); to obtain ankle circumference on 1 of 1 with ankle circumference ordered (#22); and to obtain a urinalysis on 1 of 1 patients with an urinalysis ordered (#24).

The nurse failed to complete timely documentation for 1 of 24 patients reviewed (#13).

The agency failed to send a transfer summary within 2 business days from becoming aware of the transfer for 1 of 3 patients that had a transfer to another healthcare setting (#13); and to send a discharge summary within 5 business days of discharge for 5 of 7 patients discharged from the agency…

The nursing staff failed to provide care in accordance with condition of skilled professional services for 3 of 3 discharged patients reviewed [#1, 3, and 4]. The following tags are cross referred: G706, G710, G714, and G718. The findings included: G706-- Based on clinical record review and staff…

The agency failed to track adverse patient events, analyze their causes, and implement preventive actions.

The agency failed to develop Performance Improvement Projects.

The Plan of Care [POC] did not include all medications for 4 of 13 patients [6, 8, 5, and 11]. Findings include: A policy, Plan of Care (revised 6/13/2016), was provided by the agency administrator on 11/20/18 at 4:00 p.m.

Staff interviews the Registered Nurse failed to administer drugs and treatments per physician order in regards to correct medications/dosages for 1 of 5 patients [#7] who received a home visit.

The agency failed to show evidence of an immediate corrections of identified problems that directly or potentially threaten the health and safety of patients.

The agency failed to evaluate the plan of care in coordination with the patient for 1 of 3 discharged patient requiring weight monitoring [4]. Findings include: Patient #4 was admitted on 4/10/18 with a diagnosis of atherosclerotic heart disease and chronic obstructive pulmonary disease (lung…

A review of the clinical record, hospital discharge orders and staff interviews revealed the agency failed to follow Physician's orders regarding Lasix [fluid pill], thickened liquids, and INR [blood test done to measure how quickly the blood clots] for 1 of 3 discharged charts reviewed [#3]; and…

Staff the Registered Nurse [RN] and Licensed Practical Nurse [LPN] provided interventions/education inconsistent for a patient with heart failure and using anticoagulation [blood thinner] therapy for 1 of 3 discharged charts [#3]. The findings included: According to the ANA, "MD will tell you how…

Hospital records and interviews with staff the SN failed to communicate a change in the patient's condition for 1 of 3 discharged charts [#3]; to notify the physician of episodes of hyper/hypoglycemia for 1 of 1 discharged clients with history of Ketoacidosis with [#1], and to notify the physician…