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Deficiency Records for Majestic Mountain Care Center
A list of the most recent deficiencies for Majestic Mountain Care Center. 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 Majestic Mountain Care 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-15 | 2024-10-14 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-08-07 | 2024-09-05 | 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 | 2024-08-07 | 2024-09-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-08-07 | 2024-09-05 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-08-07 | 2024-08-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-07 | 2024-08-29 | 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 | 2024-08-07 | 2024-08-29 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-08-07 | 2024-08-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-07 | 2024-08-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-08-07 | 2024-08-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-08-07 | 2024-08-29 | 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 | 2024-08-07 | 2024-08-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-07 | 2024-08-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-07 | 2024-08-29 | 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 | 2024-08-07 | 2024-08-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-07 | 2024-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-07 | 2024-08-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-15 | 2024-07-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-06 | 2024-05-17 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-01 | 2024-03-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-01 | 2024-03-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-29 | 2024-01-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-13 | 2023-11-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-13 | 2023-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-13 | 2023-11-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-09 | 2023-09-01 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-08-09 | 2023-09-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-23 | 2023-05-11 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-04-05 | 2022-05-13 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-08-30 | 2019-11-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-08-30 | 2019-11-22 | 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 | 2019-08-30 | 2019-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-30 | 2019-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-30 | 2019-11-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-08-30 | 2019-11-22 | 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 | 2019-08-30 | 2019-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-30 | 2019-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-30 | 2019-11-22 | N |
| Keep all essential equipment working safely. | Health | 2019-08-30 | 2019-11-22 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-02 | 2019-10-28 | 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 | 2019-10-02 | 2019-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-02 | 2019-10-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-09-21 | 2019-01-15 | 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 | 2018-09-21 | 2019-01-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-09-21 | 2019-01-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-21 | 2019-01-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-21 | 2019-01-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-21 | 2019-01-15 | 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 | 2018-09-21 | 2019-01-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-21 | 2019-01-15 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-21 | 2019-01-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-09-21 | 2019-01-15 | N |
| Provide or obtain dental services for each resident. | Health | 2018-09-21 | 2019-01-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-09-21 | 2019-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-21 | 2019-01-15 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-09-21 | 2019-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-21 | 2019-01-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Develop a communication plan. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Use approved construction type or materials. | Fire Safety | 2018-11-29 | 2018-12-24 | 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 | 2018-11-29 | 2018-12-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-29 | 2018-12-24 | N |
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