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Deficiency Records for The Chateau at Mountain Crest Nursing and Rehab Ctr

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.

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?
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-06-21 2024-07-06 Y
Provide or get specialized rehabilitative services as required for a resident. Health 2024-06-21 2024-07-06 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 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
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

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