Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain Top Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Failure to Provide Hygiene, Nail Care, and Hand Monitoring: A dependent resident with bilateral hand contractures, COPD, and reduced mobility did not receive consistent ADL assistance, nail care, or monitoring of a contracted hand. Staff frequently provided bed baths instead of scheduled showers, documentation of skin checks was incomplete, and the record did not show routine nail care or consistent use of ordered hand splints. The resident reported staff did not clean under the contracted fingers or assist with the splint, and an observed contracted hand had thickened elongated fungal nails, foul odor, and an open palm area where a nail had embedded, with the resident reporting pain.
Failure to Prevent Heel Pressure Injuries and Worsening Skin Breakdown A resident with severe cognitive impairment, COPD, and poor nutrition entered with existing pressure-related skin damage and later developed worsening bilateral heel wounds. The record showed no documented routine turning and repositioning, no documented heel offloading while in bed, and no documented use of protective heel boots despite orders and care plan interventions. The resident also had significant unplanned weight loss, and the wounds progressed from open draining heel injuries to unstageable pressure injuries, with the left heel later documented as Stage 4 and then Stage 3.
Failure to Monitor Weight Loss and Nutrition Needs: The facility did not timely monitor, reassess, or adjust nutrition care for residents with significant weight loss. One resident on PEG feeds had progressive, severe unplanned weight loss while the RD did not document a timely reevaluation of tube feeding or oral intake. Another resident with severe cognitive impairment and pressure injuries had missed monthly weights, continued weight loss, and meal assistance needs that were not reflected in the care plan until after surveyor inquiry. A third resident with Huntington’s disease also missed ordered monthly weights.
Delayed Response to Resident Call Bells: Multiple alert and oriented residents reported long waits for staff assistance after using call bells, with some stating they waited about 30 minutes and one resident reporting waits of 30 minutes to an hour. One resident said staff sometimes turned off the call bell without providing care and did not return until she rang again, while another said staffing shortages on day shift led to night shift helping her get up at 5:30 AM. The NHA was unable to explain the untimely responses.
Failure to Maintain Clean and Homelike Shower Rooms: A resident reported a black shower room floor and foul odor, and surveyors observed worn flooring, peeled paint, missing laminate, soap scum buildup, and damaged anti-slip strips in two shower rooms. The NHA confirmed the black floor repair did not match the floor color or maintain a homelike interior, and the DON reviewed the findings of the facility's failure to keep the shower areas clean and maintained.
Failure to Maintain Central Line and PICC Care: Two residents with CVC/PICC lines had care that did not follow MD orders or facility policy. One resident’s central line was observed without a dressing, with IV tubing left unlabeled and without a sterile end cap, while another resident’s PICC dressing was overdue, several IV antibiotic doses were left undocumented on the MAR, and arm circumference monitoring was inconsistent despite a documented increase. An LPN confirmed the observations, and the DON reviewed and confirmed the findings.
Failure to consistently offer evening snacks: Facility policy required an HS snack for all residents and no more than 14 hours between dinner and breakfast, but the posted meal schedule exceeded 14 hours for multiple resident groups. In a resident council interview, all six residents said evening snacks were not offered, and the NHA could not provide documentation showing snacks were consistently provided.
Failure to Assess Self-Administration of Medications: A cognitively intact resident with COPD and emphysema had inhaled and nasal medications left at the bedside, along with hydrocortisone cream reportedly obtained from a dermatologist and used as needed. The record did not show an assessment or order allowing self-administration, and an RN confirmed there was no active order for self-administration.
The facility failed to keep code status documentation consistent for 3 residents with moderately impaired cognition. One resident’s care plan still listed DNR even though the physician order and POLST showed Full Code, another resident had a POLST for CPR/Attempt Resuscitation but no matching physician code order, and a third resident had a DNR physician order but an incomplete POLST with the CPR/DNR section left blank. The DON confirmed the discrepancies.
A resident with reduced mobility and COPD was injured after an aide responded alone to a call bell, placed the resident on a bedpan, and then asked the resident to roll over despite a care plan requiring two staff members for all bed mobility. The resident rolled off the bed, struck the head, and later required ED care for a forehead laceration, bruising, and a hand fracture. The DON confirmed the aide did not follow the resident’s care plan.
Failure to Update Comprehensive Care Plan for Current Orders and Treatments: A resident with COPD, DM, CHF, and moderately impaired cognition had a care plan that did not match current physician orders and treatments. The plan still listed DNR instead of full code, did not reflect continuous O2 at 4 L NC, an updated fluid restriction, Apixaban, Humalog sliding-scale insulin, or PICC/IV ABX therapy. The DON confirmed the care plan had not been reviewed and revised to reflect the resident’s current medical status and required interventions.
Medication Given Outside Ordered BP Parameters: A resident with a history of stroke and L hemiplegia had an order for Midodrine HCL via PEG tube before meals for hypotension, with instructions to hold the medication if systolic BP was greater than 100 mmHg. Nursing staff administered the medication 15 times when the resident’s systolic BP was above the ordered hold parameter, and the DON acknowledged that staff did not follow acceptable standards of nursing practice related to medication administration.
Unassessed Access to Scissors: A resident with major depressive disorder, anxiety, intact cognition, and extensive ADL assistance was observed with scissors within immediate reach at the bedside. The record had no documented assessment of the resident’s ability to safely possess or use scissors, no interdisciplinary evaluation of sharp-object risk, and no documentation of safety interventions or care plan revision addressing access to scissors.
Failure to Reassess Foley Catheter Need: A resident with COPD and morbid obesity had a Foley catheter continued after admission, but the chart lacked ongoing MD/CRNP documentation supporting the catheter's continued clinical need. The resident said the catheter was placed during a hospitalization while intubated, had not previously needed catheterization, and wanted it removed; the DON confirmed there was no physician documentation clinically supporting continued Foley use.
A resident with vascular headaches and peripheral neuropathy had an order for Oxycodone 5 mg PO q4h PRN for severe pain rated 8 to 10. Review of the MAR showed staff gave the medication multiple times when the documented pain score was below the ordered threshold, including scores of 7, 6, 5, 4, 1, and 0. The DON acknowledged staff administered the narcotic outside the physician-ordered pain scale parameter.
A resident receiving PRN oxycodone had repeated mismatches between the MAR and narcotic log, with doses documented on one record but not the other. Facility narcotic count sheets also had multiple missing RN signatures across several carts and shifts, and an RN stated she had not signed because she had not yet verified the count, despite policy requiring the oncoming and off-going nurses to count together at shift change.
Improper Dating and Storage of Multi-Dose Insulin Pens: A medication cart contained opened multi-dose Insulin Aspart and Insulin Lispro pens that were available for resident use but lacked opened dates and expiration dates. One Insulin Aspart pen had an opened date documented, but no expiration date, and it remained in the cart beyond the manufacturer’s 28-day discard timeframe. An RN confirmed the pens were actively being used and were not labeled as required, and the DON reviewed the findings.
Failure to verify an LPN license upon hire: An LPN was observed working on a unit even though the personnel file did not contain proof of a valid PA license at the time of hire. The DON stated the LPN had been sent home after HR found inadequate proof of licensure, and time punches showed the LPN worked multiple shifts before the license was issued. Facility policy required license verification prior to or upon employment before direct resident care could be provided.
Failure to notify a resident and the resident's representative in writing of transfer reasons. Record review showed a resident was sent to a community hospital and later readmitted, but the facility could not provide documentation that the resident or representative was informed in a language and manner they understood. The NHA was also unable to produce evidence of the required notification.
A resident with chronic respiratory failure, hypoxia, diabetes, and moderate cognitive impairment, who required two-person assistance for bed mobility, was left unattended on her side in bed by a nurse aide during incontinence care. The resident rolled out of bed and sustained a facial injury and nasal fracture. The bed was not in the lowest position, and the DON confirmed the resident should not have been left alone.
The facility failed to maintain two doors with self-closing devices, affecting one smoke compartment. Observations revealed that the doors at Nurse's Station 2 and Resident Room 62 did not positively latch into their frames. This issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain the sprinkler system, affecting one of two floors. Three sprinkler heads in the basement laundry were found loaded with lint. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to ensure the right set of double doors in the Main dining room positively latched into the frame, as observed during a survey. This deficiency was confirmed in an interview with the Facility Administrator and Facilities Manager.
Mountain Top Rehabilitation and Healthcare Center failed to transmit MDS assessments to the CMS QIES ASAP System within the required 14-day timeframe for six residents. The assessments, including quarterly and end-of-stay evaluations, were not completed or submitted on time, as confirmed by the RNAC. This non-compliance was identified during a survey completed in April 2025.
A facility failed to accurately reflect a resident's hospice care status in their MDS assessment. The resident, admitted with Alzheimer's and malnutrition, was receiving hospice services, but the MDS assessment incorrectly noted otherwise. This was confirmed by the DON during an interview.
A resident with dementia experienced significant weight loss, but the facility failed to update the care plan to reflect this change. Despite nutritional interventions by the dietitian, the care plan had not been revised since the resident's admission, and the oversight was confirmed by the Nursing Home Administrator during a survey.
The facility did not document the accounting and disposition of medications for a resident upon discharge. The resident was admitted and later discharged, but by the time of the survey, there was no evidence in the clinical record regarding the medications' accounting or disposition. This was confirmed during an interview with the Nursing Home Administrator.
The facility failed to develop comprehensive care plans for three residents, omitting critical medical devices and treatments. A resident with cardiovascular conditions and wounds lacked a care plan for their pacemaker and wound treatment. Another resident's care plan did not include their cardiac pacemaker, and a third resident's use of TED stockings was not documented. The DON confirmed these deficiencies.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. One resident did not receive the prescribed bowel protocol despite not having a bowel movement for six days, with no evidence of timely physician notification. Another resident was observed not wearing TED stockings as ordered for edema management. Staff interviews confirmed these oversights, indicating a lack of adherence to professional standards and physician orders.
The facility failed to address significant weight loss in two residents, with one losing 7.93% of body weight in 29 days and the other 10.7% over 180 days. The dietitian did not identify or act on these changes, and the care plans lacked necessary interventions. The physician and resident representatives were not notified, leading to a deficiency in maintaining nutritional health.
A resident with a prescription for a Lidocaine pain patch experienced delays in administration, with the patch often applied more than an hour late, causing significant pain. The facility's policy requires medications to be administered within one hour of the prescribed time, but this was not followed, as confirmed by staff and records.
The facility failed to follow pharmacy procedures for controlled drug reconciliation on two medication carts. The policy requires nurses to count and sign off on controlled medications at shift changes, but signatures were missing on several dates. Interviews confirmed the expectation for nurses to sign the logs, and the DON acknowledged this requirement.
A resident with acute systolic congestive heart failure experienced a significant weight gain, which was not reported to the physician as required by the facility's policy. The resident's weight increased by 8.8 pounds in one day, a 6.48% gain, but no re-weight was taken the next day, and the physician was not notified. The facility dietitian confirmed this failure to follow protocol.
Failure to Provide Hygiene, Nail Care, and Hand Monitoring
Penalty
Summary
The facility failed to provide a dependent resident with consistent assistance for bathing, personal hygiene, nail care, and monitoring of a contracted hand. The resident was admitted with reduced mobility and COPD, was cognitively intact, and had bilateral hand contractures affecting digits three through five of both hands. The care plan required staff assistance with bathing, nail checks and trimming on bath days and as needed, and use of bilateral carrot splints at night. The resident also preferred showers, but the record showed that bed baths were frequently provided instead of the scheduled showers, and the clinical record did not contain documentation that the resident refused those showers. Facility records showed repeated gaps in documentation of required skin inspections and no documented assessment of the contracted fingers or palm area. Although weekly licensed nurse skin inspections were signed off as completed on several dates, the record did not contain the results of those assessments. The record also did not show any documented nail care from November 2025 through the survey end date, despite the facility policy requiring nail care documentation and the resident’s care plan directing staff to check, clean, and trim nails. The resident stated staff washed the tops of the hands during showers but did not wash underneath the contracted fingers, and also stated staff did not assist with placing the carrot splint into the right hand as directed. On observation, the resident’s contracted right hand had a strong foul odor, thickened and elongated mycotic fingernails, and the middle fingernail curling into the palm. An open area measuring 1.2 cm was identified in the mid-palm where the nail had embedded. The resident reported pain and stated the fingernails had grown long enough to dig into the palm, and that the resident had used teeth to tear off the elongated portion of the nail. The facility’s records did not demonstrate consistent provision of the required hygiene and grooming care or timely identification of the developing skin breakdown, and the resident developed an open wound to the palm that required treatment.
Failure to Prevent Worsening Heel Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent worsening of existing pressure-related skin damage and to prevent new pressure injuries for a resident admitted with pressure-induced deep tissue damage of the sacrum. The resident also had severe cognitive impairment with a BIMS score of 4, chronic obstructive pulmonary disease, and later experienced clinically significant unplanned weight loss, including more than 5 percent loss within 30 days and 10 percent within four months. A care plan identified risk for impaired skin integrity and included interventions such as turning and repositioning as needed and elevating heels off the mattress, and a physician order required heel offloading while in bed for heel protection. The record showed no documented evidence that the resident’s heels were elevated off the mattress as ordered, and no documented evidence that routine turning and repositioning interventions were implemented from November 2025 through January 2026. Repositioning was documented only as a non-pharmacological intervention before pain medication rather than as a scheduled preventive intervention. The facility also discontinued the heel offloading order during a hospitalization and did not renew it upon readmission. In addition, although the resident had ongoing weight loss and undernutrition, the facility did not document consistent weight monitoring or additional nutritional interventions beyond protein supplementation. A therapy note documented open draining wounds on both heels, with the left heel measuring 3.5 cm by 1.5 cm and the right heel measuring 5.0 cm by 3.5 cm with moderate sanguineous drainage. An external wound care provider later noted protective heel boots at bedside and reported nursing staff said the resident refused to wear them, but the clinical record contained no documentation that heel boots were implemented or that the resident refused them. Subsequent wound care notes showed bilateral heel injuries assessed as unstageable, with the left heel later documented as Stage 4 and then Stage 3. During survey observation, the right heel still had slough and drainage and the left heel remained open with drainage. The Nursing Home Administrator was unable to provide documentation that the recommended interventions, including turning and repositioning, floating heels while in bed, and protective heel boots when out of bed, had been implemented, and no documentation was provided showing the heel injuries were unavoidable.
Failure to Monitor and Reassess Nutritional Status
Penalty
Summary
The facility failed to maintain residents’ nutritional status by not timely reassessing, monitoring, and adjusting nutrition interventions in response to significant weight loss. One resident with a history of cerebral infarction, left-sided hemiplegia, dysphagia, and PEG tube feeding had physician-ordered NPO status with continuous enteral nutrition and water flushes. After returning from the hospital, the resident’s weight declined from 174 pounds to 160.4 pounds in 6 days, then to 146.6 pounds, and ultimately to 137.2 pounds, a 36.8-pound unplanned loss over a little more than 2 months. The record showed no documented evidence that the RD reevaluated the tube feeding regimen or overall nutritional needs during the period of progressive decline, and there was no documentation that the facility identified the ongoing significant weight loss in accordance with its policy thresholds. The same resident later had a puree diet ordered after a video fluoroscopy showed no aspiration or penetration, but the record showed the RD did not document awareness of the diet change until 8 days later. The resident reported feeling full from tube feeding and not wanting to eat some meals, and the RD then reduced tube feeding to overnight administration. After the resident’s weight fell further to 137.2 pounds, the RD documented significant weight loss within one month, noted minimal oral intake, and increased tube feeding and liquid protein. During interviews, the resident stated he did not like puree foods and was not eating much, and the RD and DON confirmed there was no documented evidence that nutritional needs had been reevaluated between the December assessment and the later February documentation despite the significant weight loss. A second resident with severe cognitive impairment, COPD, underweight status, and pressure-induced deep tissue damage of the sacrum also experienced significant weight loss without timely monitoring and intervention. The resident weighed 154 pounds on admission and 144 pounds about one month later, a 6.49 percent loss, but there was no documented evidence that the RD or physician was notified at that time. The resident then had no documented weight for January despite the facility policy requiring monthly weights, and the next recorded weight showed 138.6 pounds, a 10 percent loss in less than 4 months. The record also showed bilateral unstageable pressure injuries, meal intake often below 50 percent, and a later OT discharge summary indicating the resident required moderate assistance with eating, while the care plan had not been updated to reflect the increased assistance need until after surveyor inquiry. The facility also failed to obtain ordered monthly weights for a third resident with Huntington’s disease. Physician orders required monthly weights, but the record contained weights only for October, November, and December, with no documented January or February weight until after surveyor inquiry. The Nursing Home Administrator confirmed the missed monthly weight. Across these residents, the record showed failures to timely monitor weight trends, notify clinicians, reassess nutritional needs, and document or implement nutrition-related interventions in accordance with facility policy and physician orders.
Delayed Response to Resident Call Bells
Penalty
Summary
The facility failed to provide care in a manner that promotes and enhances each resident’s dignity and quality of life by not responding in a timely manner to residents’ requests for assistance. During a resident group interview on February 19, 2026, five out of six alert and oriented residents present reported concerns about long wait times for care. Resident 64 stated he often waits 30 minutes to an hour after ringing his call bell for assistance and said this has been an ongoing concern. Resident 101 stated she usually waits 30 minutes for staff to respond and reported that staff sometimes enter her room, turn off her call bell, and do not provide care before leaving without returning until she rings again. Resident 80 reported long wait times for care and stated there is not enough staff to get her up on the day shift, so night shift staff assist her out of bed and get her ready for the day at 5:30 AM. Residents 19 and 58 each reported waiting about 30 minutes for staff to respond to their call bells and said they understand staff are busy but are frustrated by the delays. During an interview on February 20, 2026, the nursing home administrator was informed of these concerns and was unable to explain why residents were reporting untimely staff responses to requests for assistance and care.
Failure to Maintain Clean and Homelike Shower Rooms
Penalty
Summary
The facility failed to provide housekeeping and maintenance services to keep resident shower areas clean, orderly, and homelike in two shower rooms. A cognitively intact resident reported that the shower room floor was black and that the room often had a foul odor. Observation of the Unit 2 shower room showed a faded, heavily worn floor with a 14 inch by 7 inch black oval area leading into the shower stall, peeled paint on the shower stall floor, and a missing 2 inch by 1 inch piece of plastic laminate from the front corner of the sink area. Observation of the Unit 1 shower room showed a buildup of what appeared to be soap scum on the shower floor, 14 black anti-slip strips with 7 lifted on the sides and not intact, and two strips with black hair attached to the lifted edges. The bariatric shower bed in the Unit 1 bathroom was dry, visibly not in use, and had a buildup of powder in the corners. The NHA confirmed the black area on the Unit 2 floor was epoxy used to repair the floor in the past, did not match the floor color, and was not applied in a manner to maintain a homelike interior. The NHA and DON acknowledged the facility's environment should be kept in good repair and maintained in a clean and homelike manner.
Failure to Maintain Central Line and PICC Care
Penalty
Summary
The facility failed to provide person-centered care as prescribed and failed to follow physician orders for the management of a central venous catheter and a PICC line for two residents. Facility policy required sterile dressing changes when dressings became damp, loosened, soiled, or wet, at least every seven days, and required staff to report signs and symptoms of complications to the physician, supervisor, and oncoming shift. The policy also required IV tubing changes every 24 hours or if contamination was suspected, with tubing labeled with the date, time, and initials and a sterile end cap placed when tubing was disconnected. Resident 3 had diagnoses including COPD and diabetes and a BIMS score of 12, indicating moderately impaired cognition. Outside hospital documentation showed a central venous catheter was inserted into the right chest, and physician orders directed staff to maintain the PICC line, keep an emergency kit at the bedside, and change the central line dressing and caps every seven days and as needed. On observation, the central line in the right chest had no dressing in place, the resident stated the dressing had fallen off and did not know how long it had been off, and an empty antibiotic bag was attached to IV tubing that was not labeled with a date, time, or initials. The tubing was hanging freely without a sterile end cap, and an LPN confirmed these observations. Resident 75 had diagnoses including cauda equina syndrome and osteomyelitis and a BIMS score of 11, indicating moderately impaired cognition. Outside hospital documentation showed a PICC line was inserted in the right arm, and physician orders directed staff to change the PICC dressing and caps every seven days and as needed, administer Cefepime HCL intravenously three times daily, and measure and document upper arm circumference every evening shift. The PICC dressing remained dated February 8 and was overdue for change on February 15, with the scheduled dressing change left blank on the TAR. Several ordered Cefepime doses were left blank on the MAR and not signed as administered. Arm circumference documentation was inconsistent, with blank entries and measurements that increased from 22 cm to 25 cm and then 27 cm, and the LPN stated she was unsure why there was a discrepancy, why the increase was not investigated, and why the physician was not notified. The DON reviewed and confirmed the findings.
Failure to Consistently Offer Evening Snacks
Penalty
Summary
Meals and snacks were not consistently served at times in accordance with residents’ needs, preferences, and requests. The facility policy titled Dining Options for Meal Service, last reviewed on February 2, 2026, stated that meals would be served according to the community dining schedule and that no more than 14 hours could pass between the evening meal and breakfast, and that an HS snack must be offered to all residents. However, the scheduled mealtimes showed that dinner was served at 5:00 PM and breakfast the next day was scheduled at varying times that exceeded 14 hours for residents in multiple room groups, including 14 hours and 15 minutes, 14 hours and 30 minutes, 14 hours and 45 minutes, and 15 hours between dinner and breakfast. During a resident council interview, six out of six residents stated that a snack was not offered between dinner and breakfast the following day. One resident reported that only one nurse offered evening snacks and that she was not a regular nurse, while the other residents stated they were not offered evening snacks. When the information was reviewed with the NHA, the NHA was unable to provide documented evidence that snacks were consistently offered in the evening and confirmed that it was the facility’s policy to offer nourishing snacks in the evening.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that self-administration of medications was clinically appropriate for one resident who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD and emphysema. The facility policy stated that residents may self-administer medications only when the interdisciplinary team determines it is clinically appropriate and safe, with that decision documented in the medical record and care plan. However, the clinical record did not show any documented assessment or determination that the resident was safe to self-administer medications. During observation, the resident had Trelegy Ellipta inhaler, Deep Sea Nasal Solution, and hydrocortisone cream 1% at the bedside. The resident stated that staff leave her medications for her, that she returns them to the medication cart after use, and that the hydrocortisone cream from her dermatologist remains at her bedside for use as needed. The record did not contain an order for the hydrocortisone cream or outpatient documentation confirming it, and an RN confirmed the resident did not have an active order to self-administer medications. The DON also reviewed the findings and acknowledged the facility failed to assess the resident for safe self-administration as required by policy.
Inconsistent Advance Directive and Code Status Documentation
Penalty
Summary
The facility failed to ensure residents’ rights to formulate and have advance directives implemented by maintaining accurate and consistent documentation of resuscitation status across care plans, physician orders, and POLST forms for 3 of 29 residents reviewed. Facility policy stated that residents have the right to formulate advance directives and that POLST forms are used to record treatment wishes so emergency personnel know what treatments the resident wants in a medical emergency. The cited deficiencies involved Resident 3, Resident 75, and Resident 103, all of whom had moderately impaired cognition based on BIMS scores in the 11 to 12 range. For Resident 3, the comprehensive care plan identified the resident’s code status as DNR and included a goal that the preference would be honored, but a physician order identified the resident as Full Code. A POLST form also indicated the resident elected CPR/Attempt Resuscitation. The facility did not revise the care plan to reflect the Full Code status until after surveyor inquiry, leaving the care plan inconsistent with the resident’s current resuscitation preference for over two months. For Resident 75, the record contained a completed and signed POLST indicating CPR/Attempt Resuscitation, but the current physician orders through the end of the survey did not include any code status order. For Resident 103, the physician order identified the resident as DNR, but the POLST form was incomplete because Section A, which documents CPR or DNR status, was left blank. Following surveyor inquiry, the facility obtained an updated POLST signed by the resident’s representative. The DON confirmed these findings on February 20, 2026.
Failure to Follow Two-Staff Bed Mobility Care Plan
Penalty
Summary
The facility failed to protect one of 21 sampled residents from neglect when staff did not follow the resident’s individualized care plan requiring the assistance of two staff members for all bed mobility. Resident 34 was admitted with reduced mobility and COPD, and the annual MDS dated November 12, 2025, showed the resident was totally dependent for bathing, required moderate assistance with multiple ADLs, and was cognitively intact with a BIMS score of 15. The care plan initiated January 11, 2025, identified an ADL self-care deficit related to shortness of breath and weakness and required two staff members for all bed mobility. The task list report also reflected an assistance level of two employees for all care. On September 20, 2025, Resident 34 experienced a fall from bed. The nurse documented finding the resident lying prone on the floor next to the left side of the bed and noted that the resident required a four-person assist to be rolled, with a 3 cm by 3 cm laceration above the left eyebrow. In a written statement, Employee 8 stated she responded to the resident’s call bell, placed the resident on a bedpan, and then asked the resident to roll over after completing care. Employee 8 documented that the resident rolled off the bed onto the floor and that she knew the resident required two staff members but proceeded alone because no other staff member was available. The resident later stated she had requested help to use the bathroom and told Employee 8 she was on the edge of the bed when asked to roll over, but Employee 8 said she would roll her and the resident then rolled off the bed and hit her head. Subsequent notes documented transfer to the emergency department, return with sutures to the forehead, bruising to the left eye and left hand fingers, and a later transfer for continued pain with diagnostic evaluation confirming a fracture of the left hand. The DON confirmed the investigation found Employee 8 did not follow the care plan requiring two staff members for bed mobility.
Failure to Update Comprehensive Care Plan for Current Orders and Treatments
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that reflected Resident 3’s current medical status and required interventions. Resident 3 was admitted with diagnoses including COPD, diabetes, and CHF, and an annual MDS showed moderately impaired cognition with a BIMS score of 12. The resident also had physician orders and a POLST indicating full code status, but the comprehensive care plan most recently revised on February 13, 2026, still identified the resident’s code status as DNR and did not include updated goals, interventions, or monitoring for the resident’s full code status. The care plan also did not reflect several current treatments and orders. A physician ordered oxygen at 4 liters via nasal cannula continuously for COPD, but the care plan did not include updated goals, interventions, or monitoring for continuous oxygen therapy. The resident also had a physician order for a fluid restriction of 1800 ml per day, but the care plan continued to reflect a 2200 ml fluid restriction and did not include updated goals, interventions, or monitoring related to the revised restriction. Additional omissions included the resident’s anticoagulant therapy, diabetes management, and IV therapy. Resident 3 had orders for Apixaban 5 mg twice daily and Humalog insulin before meals and at bedtime per sliding scale, yet the care plan did not include updated goals, interventions, or monitoring for these therapies. Outside hospital paperwork showed a central venous catheter in the right chest, and a physician ordered a PICC line with an emergency kit at the bedside and IV Ampicillin every six hours for a right knee prosthetic infection, but the care plan did not include updated goals, interventions, or monitoring for the PICC line and IV antibiotic therapy. After surveyor inquiry, the care plan was updated on February 19, 2026, and the DON confirmed the facility had failed to review and revise the care plan to accurately reflect the resident’s current medical condition, risks, and required treatments.
Medication Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
Licensed nursing staff failed to administer Midodrine HCL in accordance with the prescriber’s order for one resident who was admitted with diagnoses including cerebral infarction and left-sided hemiplegia. The order, dated December 5, 2025, directed Midodrine HCL 5 mg via PEG tube before meals for hypotension and to hold the medication for systolic blood pressure greater than 100 mmHg. Review of the MAR for December 2025 through February 18, 2026 showed 15 administrations outside the ordered parameters, with documented systolic blood pressures above 100 mmHg at the time the medication was given. The documented blood pressures at the times of these administrations included readings such as 112/68, 122/70, 102/60, 122/94, 120/60, 115/63, 111/62, 104/56, 108/58, and 118/78 mm/Hg. During an interview on February 20, 2026, the DON acknowledged that nursing staff did not follow acceptable standards of nursing practice related to medication administration. The facility policy stated that medications are to be administered as prescribed and in a safe and timely manner.
Unassessed Access to Scissors
Penalty
Summary
The facility failed to consistently implement appropriate interventions based on an individual resident’s needs to promote safety and prevent potential hazards for one resident. Resident 18 was admitted with diagnoses including major depressive disorder and anxiety, was cognitively intact with a BIMS score of 14, and required assistance from two staff members for ADLs. The resident’s care plan identified mood and behavioral symptoms related to depression, use of psychotropic medications, and the need to monitor for adverse effects such as confusion, dizziness, unsteadiness, impaired thinking, worsening depression, irritability, aggression, and suicidal ideations. During observation, Resident 18 was found lying in bed with a pair of scissors on the bedside table within immediate reach, and the resident stated she used the scissors to open mail when staff were not available. The clinical record contained no documented assessment of the resident’s ability to safely possess or use scissors, no interdisciplinary evaluation of risks associated with sharp objects, and no documentation that scissors were in the resident’s possession or that safety interventions were implemented. Staff interviews confirmed that no documented assessment had been completed to determine whether the resident could safely use or possess scissors, and the record did not show an interdisciplinary assessment, physician consultation, behavioral evaluation, or care plan revision addressing access to scissors or alternative safety measures.
Failure to Reassess Ongoing Need for Foley Catheter
Penalty
Summary
The facility failed to evaluate the clinical necessity of an indwelling Foley catheter for one resident. Resident 16 was admitted with diagnoses including COPD and morbid obesity, and a quarterly MDS showed the resident was cognitively intact. Admission physician orders included insertion and maintenance of a Foley catheter for obstructive uropathy with urinary retention, but the admission nursing evaluation documented urinary incontinence despite the catheter order. A facility Foley Catheter Justification form later noted bladder outlet obstruction and that staff would continue the Foley catheter. Physician and CRNP progress notes from November 2025 through the survey end date did not document ongoing clinical evaluation of the catheter's continued need, and they did not reference a past history of obstructive uropathy with urinary retention or provide assessment findings supporting continued use. The resident stated the Foley had been inserted during a hospitalization for respiratory failure while she was intubated, said she had not previously had urinary retention or needed catheterization, and expressed a desire to have the catheter removed. Outside hospital documentation in the referral packet did not include obstructive uropathy or urinary retention, and the DON confirmed there was no physician documentation clinically supporting continued Foley use for the resident.
Narcotic Pain Medication Given Outside Ordered Pain Scale
Penalty
Summary
The facility failed to ensure staff administered a narcotic pain medication in accordance with the physician’s order for Resident 64. The resident was admitted with diagnoses including vascular headaches and idiopathic peripheral autonomic neuropathy. On January 9, 2026, the physician ordered Oxycodone 5 mg, one tablet by mouth every four hours as needed for severe pain rated 8 to 10, using a pain scale where 8 to 10 indicated severe pain. Review of the January 2026 MAR showed staff administered Oxycodone 47 times, and 23 of those doses were given when the documented pain rating did not meet the ordered parameter of 8 to 10. Review of the February 2026 MAR showed staff administered Oxycodone 24 times, and 14 of those doses were given when the documented pain rating did not meet the ordered parameter. The report listed multiple administrations given for pain ratings of 7, 6, 5, 4, 1, and 0. The DON acknowledged on February 20, 2026, that staff administered the narcotic pain medication outside of the physician-ordered pain scale parameter for Resident 64.
Inaccurate controlled substance documentation and incomplete narcotic counts
Penalty
Summary
The facility failed to maintain accurate documentation and reconciliation of controlled substances for one resident receiving Oxycodone 5 mg PRN for severe pain. The resident was admitted with hydrocephalus and cerebral infarction, and had a physician order dated January 9, 2026 for Oxycodone 5 mg by mouth every 4 hours as needed for severe pain rated 8-10. Facility policy required medications to be documented immediately on the MAR and controlled substances to be counted and reconciled at each shift change using the narcotic inventory records. Review of the resident’s Controlled Drug Receipt/Record/Disposition Form and MAR for January and February 2026 showed repeated discrepancies. In some instances, Oxycodone 5 mg was documented on the MAR but not recorded on the narcotic log, including entries on January 13, January 19, January 22, and January 28. In other instances, Oxycodone 5 mg was signed out on the narcotic log but not documented as administered on the MAR, including multiple entries from January 15 through February 16. These inconsistencies showed the facility did not ensure accurate documentation and reconciliation of the controlled substance. Review of the Narcotic Count Sheets also showed missing signatures on multiple shift-to-shift counts for the A Hall, B Hall, and C Hall carts. Missing signatures included oncoming and off-going nurses for several shifts in January and February 2026. During interview, an RN stated she had not signed the narcotic log because she had not yet verified the count, despite policy requiring the oncoming and off-going nurses to complete the count together at shift change. The DON reviewed these findings during interview and acknowledged the facility’s failure to ensure accurate reconciliation of the resident’s controlled substances and consistent completion of required narcotic counts.
Improper Dating and Storage of Multi-Dose Insulin Pens
Penalty
Summary
The facility failed to follow acceptable storage and labeling practices for multi-dose insulin pens in one of two medication carts observed. Review of the facility policy on Medication Labeling and Storage showed that opened multi-use vials or injectables were to be dated and discarded within 28 days unless the manufacturer required a different timeframe. During observation of Unit 1 Hall Cart A, one multi-dose Insulin Aspart pen and two multi-dose Insulin Lispro pens were found opened and available for resident use without an opened date or expiration date documented, even though the pens had stickers with space to record those dates. A separate Insulin Aspart pen in the same cart was documented as opened on January 2, 2026, but no expiration date was recorded. Manufacturer safety information indicated that this pen should have been discarded 28 days after opening, on January 30, 2026, yet it remained in the medication cart and available for use beyond that timeframe. An RN confirmed that the two Insulin Lispro pens and the Insulin Aspart pen were opened, actively being used for medication administration, and were not labeled with expiration dates. The DON reviewed these findings and acknowledged the facility's failure to ensure staff followed the policy for dating and storing multi-dose insulin pens.
Failure to Verify LPN License Upon Hire
Penalty
Summary
The facility failed to ensure that professional staff were licensed, certified, or registered in accordance with state law upon hire for one of five personnel files reviewed, Employee 2, an LPN. Facility policy required nursing service personnel who need a license or certification to present verification prior to or upon employment and prohibited them from performing direct resident care until licensing and background checks were completed. Pennsylvania law and the facility policy were reviewed during the survey, and observation on February 18, 2026, at 10:30 AM showed Employee 2 working on D Hall on Unit 2. Review of Employee 2’s personnel file showed she was hired as an LPN on January 28, 2026, had completed a Practical Nursing Program Diploma, and passed the Practical Nurses Exam, but there was no evidence of a Pennsylvania Practical Nurse license in the file at the time of hire. Time punches showed she worked multiple shifts between January 28, 2026, and February 17, 2026, before a license was issued on February 18, 2026. The DON stated Employee 2 had been sent home after HR found inadequate proof of a valid Pennsylvania LPN license, and the NHA confirmed HR did not complete license verification upon hire as required by facility policy.
Failure to Notify Resident and Representative of Transfer Reasons
Penalty
Summary
The facility failed to notify Resident 98 and the resident's representative(s) in writing, and in a language and manner they understand, of the reasons for the resident's transfer to a community hospital and subsequent readmission. A clinical record review showed Resident 98 was admitted to the facility on [DATE], transferred to a community hospital on January 14, 2026, and readmitted to the facility on [DATE]. The facility was unable to provide documented evidence that the resident or the resident representative was notified of the reasons for the transfer, and during an interview on February 20, 2026, the nursing home administrator was also unable to provide such documentation.
Failure to Provide Required Assistance During Bed Mobility Resulting in Resident Fall
Penalty
Summary
A resident with chronic respiratory failure, hypoxia, and diabetes, who was moderately cognitively impaired and required extensive assistance for personal hygiene and bed mobility, was not provided the necessary care and services to prevent a fall from bed. According to the resident's care plan, two staff members were required to assist with bed mobility. However, during incontinence care, a nurse aide left the resident unattended on her side in bed to obtain washcloths, despite the resident's need for two-person assistance for bed mobility. As a result, the resident rolled out of bed and landed on her face, sustaining a raised bluish/purple area on the forehead and an acute fracture of the bony nasal septum, as confirmed by a CT scan. The bed was not in the lowest position at the time of the incident. The nurse aide involved confirmed leaving the resident alone, and the DON verified that the resident should not have been left unattended during care, which directly led to the fall.
Failure to Maintain Self-Closing Doors
Penalty
Summary
The facility failed to maintain two doors with self-closing devices, which affected one of six smoke compartments. During an observation on April 30, 2025, between 10:14 am and 10:21 am, it was noted that the doors did not positively latch into their frames. Specifically, the door at Nurse's Station 2 and the door of Resident Room 62, which is tied into the fire alarm system, were identified as not latching properly. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager at 11:00 am on the same day.
Plan Of Correction
The Nurse's Station 2 door and Resident Room 62 door assembly was adjusted to provide positive latching by facility maintenance department. The Maintenance Director/designee will conduct a facility wide audit to identify doors requiring adjustment to fully latch and coordinate repairs as identified. The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement. The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system in one location, specifically affecting one of two floors. During an observation on April 30, 2025, at 9:55 am, it was found that three sprinkler heads within the basement laundry area were loaded with lint. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:00 am.
Plan Of Correction
The 3 basement laundry sprinkler heads were thoroughly cleaned of lint. The Maintenance Director will conduct an audit of sprinkler heads within the basement laundry to verify that the sprinklers are lint free. The Nursing Home Administrator/designee will provide re-education to the Maintenance Director for the requirements for sprinkler heads being free from lint. The Maintenance Director/designee will conduct audits of random sprinkler heads to confirm that they are free of lint and verify compliance weekly audits x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Failure to Maintain Corridor Door Latching
Penalty
Summary
The facility failed to maintain a corridor opening as required by regulations, specifically concerning the doors in the Main dining room. During an observation on April 30, 2025, at 10:46 am, it was noted that the right set of double doors in the Main dining room did not positively latch into the frame. This deficiency affects one of the two floors in the facility. The issue was confirmed during an exit interview with the Facility Administrator and the Facilities Manager on the same day at 11:00 am. The failure of the doors to positively latch is a violation of the requirements for corridor doors, which are supposed to resist the passage of smoke and have positive latching hardware, especially in fully sprinklered smoke compartments.
Plan Of Correction
The main dining room right set of double doors' door assembly was adjusted to provide positive latching by facility maintenance department. The Maintenance Director/designee will conduct a facility wide audit of double doors to identify doors requiring adjustment to fully latch and coordinate repairs as identified. The Nursing home Administrator will provide re-education to the Maintenance Director on proper door latching requirement. The Maintenance Director will conduct audits on latching doors to verify compliance weekly x 4 weeks, then monthly x 2 months. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
Mountain Top Rehabilitation and Healthcare Center was found to be non-compliant with the requirements of 42 CFR Part 483 Subpart B, specifically regarding the encoding and transmission of Minimum Data Set (MDS) assessments. The facility failed to transmit MDS assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for six residents. These residents' assessments, which included quarterly and end-of-stay evaluations, were not completed or submitted on time, as evidenced by the clinical record reviews and staff interviews. The Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS assessments for the residents were not completed and submitted within the mandated period. The assessments for Residents 70, 77, 58, 100, 78, and 47 were all delayed, with some remaining incomplete and unsubmitted through the survey's conclusion. This failure to adhere to the required timelines for MDS data submission was identified during the Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on April 18, 2025.
Plan Of Correction
F0640 - Encoding /Transmitting Resident Assessment A. Corrective action taken for residents identified: Residents #70, #77, #58, #100, #78, #47 - outstanding MDS completed and submitted. B. Registered Nurse Assessment Coordinator or designee will conduct an initial audit of open MDS assessments to review for timely completion. Findings will be addressed and corrected. C. Nursing Home Administrator or designee will re-educate on the required assessment completion and transmission timeframes per CMS regulations. D. Nursing Home Administrator or designee will complete an MDS tracking form weekly x6 weeks of completed assessments, to for timeliness. Any variances of completion or submission within regulatory timeframes will be addressed, and results will be shared with QA committee for review.
Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. Resident 49, who was admitted with Alzheimer's disease and protein-calorie malnutrition, was receiving hospice services. However, the quarterly MDS assessment dated December 20, 2024, inaccurately indicated that the resident was not receiving hospice care. This discrepancy was confirmed during an interview with the Director of Nursing on April 17, 2025, who acknowledged that the resident was indeed receiving hospice care during the period in question.
Plan Of Correction
F0641 - Accuracy of Assessments A. Resident #49: MDS assessment modified and resubmitted to reflect the accurate assessment. B. Registered Nurse Assessment Coordinator will conduct an initial audit to identify other residents/MDS assessments with coding discrepancies for item 00110K1 (hospice). All findings will be addressed. C. Nursing Home Administrator or designee will re-educate the Registered Nurse Assessment Coordinator on RAI Manual guidelines related to 00110K1 coding. D. Nursing Home Administrator or designee will audit 00110K1 of completed MDS assessments, weekly x6 weeks, to ensure accuracy. Inaccurate coding will be addressed upon identification and results will be shared with QA committee for review.
Failure to Update Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to review and revise the care plan for a resident who experienced significant weight loss. The resident, admitted with diagnoses including dementia, showed an 8.5% weight loss over 90 days as of March 18, 2025. Despite the registered dietitian implementing nutritional interventions, the care plan had not been updated since December 13, 2023, to reflect the resident's current nutritional status and needs. During a survey conducted in April 2025, it was found that the care plan did not include updates or new interventions addressing the resident's weight loss. The Nursing Home Administrator confirmed the oversight, acknowledging that the care plan should have been reviewed and revised in response to the significant change in the resident's condition.
Plan Of Correction
F Tag 0657: 1. Resident 91's plan of care was updated to reflect weight changes with implementation of appropriate interventions. 2. Director of Nursing or Designee will conduct an initial of residents with significant weight changes to verify that their individualized plans of care were completed addressing current weight significant changes and implementation of interventions as warranted. 3. Director of Nursing or Designee will be provided re-education to the Interdisciplinary Care Team on Comprehensive Plans of Care updating/reviewing reflecting weights. 4. Director of Nursing or designee will conduct audits on residents identified as having significant weight changes to verify care plans and implementation of interventions as warranted. The audits will be conducted weekly x 4 weeks and monthly x 3 months. Results of these audits will be brought to the QAPI Committee for review and recommendations.
Failure to Document Medication Disposition for Discharged Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 109 upon discharge. Resident 109 was admitted on November 6, 2024, and discharged on January 29, 2025. However, by the time of the survey, which concluded on April 18, 2025, there was no documented evidence in the resident's clinical record regarding the accounting of remaining medications or their disposition at the time of discharge. This deficiency was confirmed during an interview with the Nursing Home Administrator on April 18, 2025, at 10:30 AM.
Plan Of Correction
P 5280 - Disposition of Medications 1. The facility cannot retroactively correct said deficiency. 2. Residents discharged within the last 14 days will be reviewed by the Director of Nursing or Designee to verify proper documentation for disposition of medications occurred. 3. Director of Nursing or Designee will re-educate licensed nurses on documentation of disposition of medications. 4. Director of Nursing or Designee will conduct audits of discharged residents daily x 2 weeks, weekly x 4 weeks and monthly x 2 months to ensure proper documentation of disposition of medications occurred. Results of these audits will be reviewed by the facility's QAPI Committee for review and recommendations.
Deficiency in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, leading to deficiencies in meeting their medical and treatment needs. Resident 53, who was admitted with multiple cardiovascular conditions and wounds, had a care plan that did not address the presence of an implantable pacemaker or the treatment for arterial and venous wounds on the lower extremities. Similarly, Resident 55's care plan did not include the presence of a cardiac pacemaker, despite the resident's admission with acute systolic congestive heart failure and other cardiovascular issues. Resident 64, with a history of venous thrombosis and embolism, had a physician's order for the use of TED compression stockings, which was not reflected in the care plan. The Director of Nursing confirmed that the facility did not ensure comprehensive care plans were developed to meet the residents' medical and treatment needs, as required by 28 Pa. Code 211.12 (d)(5) Nursing services.
Failure to Follow Physician Orders for Bowel Protocol and Compression Stockings
Penalty
Summary
The facility failed to adhere to physician orders for two residents, resulting in deficiencies in care. For one resident, the facility did not follow a prescribed bowel protocol, which included administering Milk of Magnesia, Dulcolax suppository, and a Fleet enema as needed for constipation. Despite the resident not having a bowel movement for six days, there was no documented evidence that the bowel protocol was administered, nor was there timely notification to the physician. The resident's clinical records showed multiple blank entries regarding bowel activity, indicating either incomplete tasks or failure to document by the staff. Another resident had a physician's order for the application of TED stockings to the right lower extremity to manage edema. Observations over several days revealed that the resident was not wearing the TED stocking as ordered. Interviews with staff confirmed the oversight, and the Nursing Home Administrator acknowledged that the staff did not follow the physician's order for the application and removal of the TED stocking. These failures indicate a lack of adherence to professional standards of practice and physician orders, as required by the facility's regulations.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to accurately and consistently assess the nutritional status of two residents, leading to significant weight loss that was not timely addressed. Resident 75 experienced a weight loss of 7.93% in 29 days and 6.19% in 43 days, which was not identified or acted upon by the dietitian. The dietitian confirmed that the significant weight loss in March 2024 was not recognized, and no nutritional support measures were developed or implemented at that time. Additionally, the physician and resident representative were not notified of the weight loss. Resident 51 also experienced significant weight loss, with a 10.7% decrease over 180 days. Despite the resident's history of weight loss and increased nutrient needs, the care plan did not include new interventions to address the ongoing weight loss. The dietitian did not address the weight loss until May 14, 2024, and there was no evidence that the physician or representative were notified of the weight loss. The resident's care plan did not include the intervention of sugar-free Healthshakes, which the resident was receiving three times a day. The Nursing Home Administrator confirmed that the facility was unable to demonstrate that the dietitian had identified the residents' weight loss and implemented timely measures to maintain acceptable nutritional parameters. The facility's failure to act upon the significant weight changes and notify the appropriate parties resulted in a deficiency in maintaining the residents' nutritional health.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as Resident 64, who was prescribed a Lidocaine External Patch for pain relief. The resident was scheduled to receive the patch at 9:00 AM daily, but records and interviews revealed that the administration of the patch was frequently delayed by one hour or more on multiple occasions throughout June 2024. The resident reported experiencing significant pain due to these delays, and an interview with the Assistant Director of Nursing confirmed that the patch was not applied as scheduled. The facility's policy on medication administration, which requires medications to be administered within one hour of their prescribed time, was not adhered to. The Nursing Home Administrator acknowledged that the late administration of the pain patch was inconsistent with professional standards for pain management. The deficiency was identified through a review of clinical records, facility policy, and interviews with the resident and staff, highlighting a repeated failure to provide person-centered pain management in accordance with professional standards.
Failure to Reconcile Controlled Drugs
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on two medication carts, Med cart A and Med cart D. According to the facility's policy on controlled substances, which was last reviewed on June 12, 2024, controlled medications are to be counted at the end of each shift by both the on-coming and off-going nurses, with any discrepancies reported immediately to the Director of Nursing (DON). However, during observations on June 26, 2024, it was found that the required signatures verifying the completion of the controlled drug count were missing on several dates for both medication carts. Specifically, for Med cart A, the signatures were absent on June 18, 23, and 24, 2024, and for Med cart D, the signatures were missing on June 21 and 24, 2024. Interviews with the involved staff, including an LPN and an RN, confirmed the absence of signatures and acknowledged the expectation that licensed nurses sign the count verification at shift changes. The DON also confirmed that it is the facility's expectation for nursing staff to sign the controlled substance logs at shift changes to ensure timely identification of any discrepancies. This deficiency was identified under the regulations 28 Pa. Code 211.19(a)(1)(k) Pharmacy services and 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to timely consult with the physician regarding a significant weight gain experienced by a resident. The resident, who was admitted with acute systolic congestive heart failure and had a cardiac pacemaker, showed an 8.8-pound weight gain in one day, which constituted a 6.48% increase. According to the facility's policy, any weight change of 5% or more should be retaken the next day for confirmation, and significant weight changes should be reported to the physician. However, there was no documented evidence that the physician was notified of this significant weight gain, nor was a re-weight taken the following day as required by the policy. The dietitian's note indicated that weight fluctuations were reviewed, and the physician was to be notified if a 5-pound weight gain in 7 days was noted. Despite this, the significant weight gain recorded on May 30, 2024, was not communicated to the physician, and the policy for re-weighing was not followed. An interview with the facility dietitian confirmed the failure to notify the physician in a timely manner. This oversight was a violation of the facility's policy and the state code 28 Pa Code 211.12 (d)(3)(5) regarding nursing services.
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Illustrative
What surveyors actually found near you
We read the 452 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mountain Top
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Smith Health Care Ltd | 2.4 mi | — | 0 | 0 |
| Edenbrook At Hampton | 5.4 mi | ★★★★★ | 13 | 0 |
| Birchwood Rehabilitation & Healthcare Center | 5.5 mi | ★★★★★ | 22 | 1 |
| Allied Services Meade Street Skilled Nursing | 5.8 mi | ★★★★★ | 2 | 0 |
| Allied Services Center City Skilled Nursing | 6.4 mi | ★★★★★ | 9 | 0 |
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