Deficiency Records for Mountain Top Rehabilitation and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Mountain Top Rehabilitation and Healthcare Center. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-07-28 | 2023-09-12 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-28 | 2023-09-12 | 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 | 2023-07-28 | 2023-09-12 | 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 | 2023-07-28 | 2023-09-12 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-07-28 | 2023-09-12 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-28 | 2023-09-12 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-28 | 2023-09-12 | N |
Use approved construction type or materials. | Fire Safety | 2023-07-10 | 2023-08-08 | N |
Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-10 | 2023-08-08 | 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 | 2023-07-10 | 2023-08-08 | 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 | 2022-08-19 | 2022-09-28 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-19 | 2022-09-28 | 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 | 2022-08-19 | 2022-09-28 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-19 | 2022-09-28 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-08-19 | 2022-09-28 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-19 | 2022-09-28 | N |
Use approved construction type or materials. | Fire Safety | 2022-08-09 | 2022-09-21 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-09 | 2022-09-21 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-09 | 2022-09-21 | N |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-24 | 2022-03-21 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-18 | 2021-12-22 | Y |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-11-18 | 2021-12-22 | Y |
Post nurse staffing information every day. | Health | 2021-11-18 | 2021-12-22 | Y |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-18 | 2021-12-22 | Y |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-11-18 | 2021-12-22 | Y |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-09-24 | 2021-12-22 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-24 | 2021-11-18 | N |
Respond appropriately to all alleged violations. | Health | 2021-09-24 | 2021-11-18 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-24 | 2021-11-18 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-09-24 | 2021-11-18 | N |
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2021-09-24 | 2021-11-18 | N |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-09-24 | 2021-11-18 | 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 | 2021-09-24 | 2021-11-18 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-24 | 2021-11-18 | 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 | 2021-09-24 | 2021-11-18 | N |
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-09-24 | 2021-11-18 | N |
Have policies on smoking. | Health | 2021-09-24 | 2021-11-18 | N |
Use approved construction type or materials. | Fire Safety | 2021-09-15 | 2021-10-12 | 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 | 2021-09-15 | 2021-10-12 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-15 | 2021-10-12 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-15 | 2021-10-12 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-19 | 2021-09-24 | Y |
Post nurse staffing information every day. | Health | 2021-08-19 | 2021-09-24 | 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 | 2021-06-10 | 2021-07-27 | 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 | 2021-06-10 | 2021-07-27 | Y |
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2021-06-10 | 2021-07-27 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-10 | 2021-06-10 | Y |