A list of the most recent deficiencies for Mountain Manor Senior Residence. 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-11 | 2023-06-01 | N |
| 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 | 2023-05-11 | 2023-06-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-05-11 | 2023-06-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-11 | 2023-06-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-11 | 2023-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-06-01 | 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 | 2023-05-11 | 2023-06-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-11 | 2023-06-01 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-11 | 2023-06-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-11 | 2023-06-01 | 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 | 2023-05-11 | 2023-06-01 | 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 | 2023-05-11 | 2023-06-01 | 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 | 2023-05-11 | 2023-06-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-05-11 | 2023-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-11 | 2023-06-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-06-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-11 | 2023-06-01 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-17 | 2023-06-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-17 | 2023-06-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-17 | 2023-06-01 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-06-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-17 | 2023-06-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-17 | 2023-06-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-17 | 2023-06-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-27 | 2023-05-08 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-06-16 | 2022-07-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-22 | 2022-05-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-02-28 | 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 | 2022-01-13 | 2022-02-08 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-27 | 2019-07-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-06-27 | 2019-07-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-27 | 2019-07-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-27 | 2019-07-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-27 | 2019-07-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-27 | 2019-07-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-16 | 2019-06-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-16 | 2019-06-07 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-05-16 | 2019-06-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-16 | 2019-06-07 | 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 | 2019-05-16 | 2019-06-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-05-16 | 2019-06-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-16 | 2019-06-07 | N |
| Dispose of garbage and refuse properly. | Health | 2019-05-16 | 2019-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-16 | 2019-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-17 | 2018-06-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-17 | 2018-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-17 | 2018-06-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-30 | 2018-06-13 | N |
