Deficiency Records for The Chateau at Mountain Crest Nursing and Rehab Ctr
Updated as of April 01, 2024
A list of the most recent deficiencies for The Chateau at Mountain Crest Nursing and Rehab Ctr. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-23 | 2024-01-30 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-01-18 | 2024-01-30 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-18 | 2024-01-30 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-18 | 2024-01-30 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-18 | 2024-01-30 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-09-11 | 2023-09-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-24 | 2023-06-08 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-24 | 2023-06-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-04 | 2023-06-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-04 | 2023-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-25 | 2023-06-08 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-11-15 | 2023-02-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-11-15 | 2023-02-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-15 | 2023-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-15 | 2023-02-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-15 | 2023-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-15 | 2023-02-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-15 | 2023-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-15 | 2023-02-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-01 | 2023-01-26 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-01 | 2023-01-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-01 | 2023-01-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-01 | 2023-01-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-12-01 | 2023-01-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-12-01 | 2023-01-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-01 | 2023-01-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-01 | 2023-01-26 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-12-01 | 2023-01-26 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-12-01 | 2023-01-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-01 | 2023-01-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-01 | 2023-01-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-01 | 2023-01-26 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-15 | 2023-01-24 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2022-12-01 | 2022-12-23 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-12-01 | 2022-12-23 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-12-01 | 2022-12-23 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-12-01 | 2022-12-23 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-01 | 2022-12-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-11 | 2022-10-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-26 | 2022-10-21 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-08-23 | 2022-10-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-23 | 2022-10-11 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-23 | 2022-10-11 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-08-23 | 2022-10-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-27 | 2022-10-11 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-06-27 | 2022-10-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-11 | 2022-03-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-11 | 2022-03-11 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-11 | 2022-03-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-11 | 2022-03-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-20 | 2022-03-11 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2021-12-29 | 2022-01-13 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-11-17 | 2021-12-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-17 | 2021-12-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-17 | 2021-12-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-17 | 2021-12-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-10 | 2021-09-22 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-10 | 2021-09-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-10 | 2021-09-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-10 | 2021-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-10 | 2021-09-22 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2021-08-10 | 2021-09-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-29 | 2021-05-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-28 | 2020-03-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-28 | 2020-03-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-28 | 2020-03-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-28 | 2020-03-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-28 | 2020-03-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-28 | 2020-03-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-10-28 | 2020-03-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-28 | 2020-03-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-28 | 2020-03-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-28 | 2020-03-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-28 | 2020-03-11 | N |
| Provide appropriate foot care. | Health | 2019-10-28 | 2020-03-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-28 | 2020-03-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-28 | 2020-03-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-28 | 2020-03-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-28 | 2020-03-11 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2019-10-28 | 2020-03-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-28 | 2020-03-11 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-10-28 | 2020-03-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-28 | 2020-03-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-28 | 2020-03-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-22 | 2020-03-11 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2018-08-09 | 2018-09-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-08-09 | 2018-09-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-09 | 2018-09-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-09 | 2018-09-10 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-08-09 | 2018-09-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-08-09 | 2018-09-10 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2018-08-09 | 2018-09-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-08-09 | 2018-09-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-09 | 2018-09-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-08-09 | 2018-09-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-08-09 | 2018-09-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-09 | 2018-09-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-09 | 2018-09-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-08-09 | 2018-09-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-09 | 2018-09-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-08-09 | 2018-09-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-08-09 | 2018-09-10 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-08-09 | 2018-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-09 | 2018-09-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-09 | 2018-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-09 | 2018-09-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-08-09 | 2018-09-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-07 | 2018-09-10 | N |
