Deficiency Records for The Chateau at Mountain Crest Nursing and Rehab Ctr
Updated as of July 01, 2021
This is not the most recent data for The Chateau at Mountain Crest Nursing and Rehab Ctr. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2021-04-29 | 2021-05-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-14 | 2021-03-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-01-14 | 2021-03-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-03 | 2021-03-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-11-10 | 2021-03-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-01-14 | 2021-03-04 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-01-14 | 2021-03-04 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2020-11-10 | 2021-03-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-11-10 | 2021-03-04 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2020-11-10 | 2021-03-04 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2020-11-10 | 2021-03-04 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2020-11-10 | 2021-03-04 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2020-11-10 | 2021-03-04 | Y |
| Have policies on smoking. | Health | 2020-11-10 | 2021-03-04 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2020-11-10 | 2021-03-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-07-30 | 2020-08-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-30 | 2020-08-24 | Y |
| 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 | 2020-07-10 | 2020-08-24 | 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 | 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 |
| Provide appropriate foot care. | 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 |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-28 | 2020-03-11 | Y |
| 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 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-28 | 2020-03-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-28 | 2020-03-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-28 | 2020-03-11 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-28 | 2020-03-11 | 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 | 2019-10-28 | 2020-03-11 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-28 | 2020-03-11 | Y |
| 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 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-28 | 2020-03-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-28 | 2020-03-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-28 | 2020-03-11 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-28 | 2020-03-11 | Y |
| 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 | Y |
| 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 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2019-10-28 | 2020-03-11 | Y |
| 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 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-10-28 | 2020-03-11 | Y |
| 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 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-04 | 2020-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-04 | 2020-03-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-03-04 | 2020-03-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-14 | 2020-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-28 | 2020-03-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-26 | 2019-09-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-26 | 2019-09-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-08-26 | 2019-09-11 | Y |
| 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 | 2019-07-10 | 2019-09-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-06-13 | 2019-09-11 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-06-13 | 2019-09-11 | Y |
| 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 | 2019-05-15 | 2019-09-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-18 | 2019-09-11 | Y |
| Provide or obtain dental services for each resident. | Health | 2018-12-19 | 2019-01-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-17 | 2019-01-09 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-10-11 | 2018-10-31 | Y |
| 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 |
| 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 |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-07-10 | 2018-08-07 | Y |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-07-10 | 2018-08-07 | Y |
| 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 | 2017-06-06 | 2017-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-06 | 2017-07-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-06-06 | 2017-07-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-06-06 | 2017-07-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-06-06 | 2017-07-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-06-06 | 2017-07-19 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-06-19 | 2017-07-19 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-06-19 | 2017-07-19 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-19 | 2017-07-19 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-06-19 | 2017-07-19 | N |
| Make sure that special or therapeutic diets are ordered by the attending doctor. | Health | 2017-06-19 | 2017-07-19 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2017-06-19 | 2017-07-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-06-19 | 2017-07-19 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-19 | 2017-06-19 | N |
