Mountain Top Rehabilitation & Healthcare Center

Inspectors wroteBased on observations, clinical record review, review of select facility policies and procedures, and staff and resident interviews, the facility failed to provide Resident 34, who was dependent on staff for activities of daily living (ADLs), with the care and services necessary to maintain proper personal hygiene and grooming, including nail care and monitoring of a contracted hand. As a result of this failure, the resident developed an open wound to the palm that required treatment and caused pain. This deficient practice resulted in actual harm for one of 29 residents reviewed (Resident 34).

Inspectors wroteBased on observations, clinical record review, review of facility policies, and staff interviews, the facility failed to ensure a resident who entered the facility with existing pressure-related skin damage received necessary care and services to prevent additional pressure injuries and prevent worsening of existing wounds. This failure resulted in actual harm, unstageable to Stage 4 pressure areas, for one of 29 residents reviewed (Resident 11.)

Inspectors wroteBased on review of clinical records, select facility policies, physician orders, weight records, MDS assessments, and staff and resident interviews, it was determined the facility failed to ensure residents maintain acceptable parameters of nutritional status to the extent possible. The facility failed to reassess and adjust enteral nutrition and oral intake in response to significant progressive weight loss for one resident (Resident 31), resulting in actual harm as evidenced by a 36.8 pound (21.1 percent) unplanned weight loss in two months. The facility further failed to timely monitor weights and implement interventions for one resident (Resident 11), resulting in continued significant weight loss and development of bilateral unstageable pressure injuries and failed to obtain ordered monthly weights for one resident (Resident 15). [...]

Inspectors wroteBased on a review of clinical records and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by failing to respond in a timely manner to residents' requests for assistance, including experiences reported by 5 out of 6 residents during a resident group interview (Residents 19, 58, 64, 80, and 101).

Inspectors wroteBased on observation and resident and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in resident areas in two of two shower rooms.

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and resident and staff interviews, it was determined the facility failed to provide person-centered care as prescribed to meet the current clinical needs and failed to follow physician orders for the management of a Central Venous Catheter (CVC) and Peripherally Inserted Central Catheter (PICC) line for two of 29 sampled residents (Residents 3 and 75).

Inspectors wroteBased on a review of scheduled facility mealtimes, select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by six out of six residents during a group interview (Residents 6, 19, 58, 64, 80, and 101).

Inspectors wroteBased on observations, a review of clinical records, and select facility policy and staff interview, it was determined the facility failed to ensure that self-administration of medications was clinically appropriate for one of the 29 residents sampled (Resident 58).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, the facility failed to ensure residents' rights to formulate and have advance directives implemented. The facility failed to maintain accurate and consistent documentation of residents' resuscitation status by failing to revise a comprehensive care plan to reflect the resident's current code status (Resident 3), ensure physician orders reflected the resident's documented resuscitation wishes (Resident 75), and obtain and maintain a completed Physician Orders for Life-Sustaining Treatment (POLST) form consistent with a physician's Do Not Resuscitate (DNR) order (Resident 103), for 3 of 29 residents reviewed.

Inspectors wroteBased on review of clinical records, facility policy, investigative documentation provided by the facility, and staff interviews, the facility failed to protect one of 21 sampled residents (Resident 34) from neglect when staff did not implement the resident's individualized care plan intervention requiring the assistance of two staff members for all bed mobility. This deficiency is cited as past noncompliance.

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan that reflected the resident's current medical status and required interventions for one of 29 residents sampled (Resident 3).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure licensed nurses accurately administered prescribed medication consistent with professional standards of practice for one of 29 sampled residents (Resident 31).

Inspectors wroteBased on observations, review of clinical records and staff and resident interview, it was determined the facility failed to consistently implement appropriate interventions based on individual resident needs to promote resident safety and prevent potential hazards for one resident out of 29 sampled residents. (Resident 18).

Inspectors wroteBased on review of clinical records, select facility policy, and resident and staff interviews, it was determined the facility failed to evaluate the clinical necessity of an indwelling urinary catheter for one resident out of 29 sampled (Resident 16).

Inspectors wroteBased on review of clinical records, facility policy, and staff interview, it was determined the facility failed to ensure staff administered a narcotic pain medication in accordance with the physician's order for one of 21 residents reviewed for medication administration, Resident 64.

Inspectors wroteBased on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for one out of the 29 residents sampled (Resident 64).

Inspectors wroteBased on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications in one of two medication carts observed (Cart A).

Inspectors wroteBased on observation, review of select facility policy, state laws, and professional licenses, as well as staff interview, it was determined the facility failed to ensure professional staff were licensed, certified, or registered in accordance with state laws upon hire for one of five personnel files reviewed (Employee 2).

Inspectors wroteBased on a review of clinical records, transfer notices, and staff interviews, it was determined the facility failed to notify the resident and the resident's representative(s) of the transfer in writing and in a language and manner they understand for 1 out of 29 residents reviewed (Resident 98).

Inspectors wroteBased on review of clinical records, select facility policy, investigation documentation provided by the facility, and resident and staff interviews, it was determined the facility the facility failed to protect one of four sampled residents (Resident 1) from neglect by not providing the care and services necessary to prevent a fall from bed. This deficiency is cited at past noncompliance.

Inspectors wroteBased on clinical record review and staff interview and review of the Resident Assessment Instrument Manual, it was determined the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for six of 22 residents reviewed (Residents 70, 77, 58, 100, 78, and 47).

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 22 sampled (Resident 49).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined the facility failed to review and revise the resident's care plan to reflect a significant change in condition related to weight loss for one of 22 residents sampled (Resident 91).

Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the needs of three out of 20 residents sampled (Residents 53, 55 and 64) Findings including: Clinical record review revealed that Resident 53 was admitted to the facility on [DATE], with diagnoses to include congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues), chronic atrial fibrillation (an irregular heartbeat), implantable cardiac pacemaker (device implanted in our body to deliver electrical impulses to your heart to help your heartbeat at a normal rate and rhythm), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and an open wound on the left ankle. [...]

Inspectors wroteBased on observation, review of clinical records, and resident and staff interview it was determined that the facility failed to provide services consistent with professional standards of practice by failing to follow physician orders for bowel protocol for one resident (Resident 75) to promote normal bowel activity to the extent practicable and failed to follow physician orders for the consistent application of a prescribed therapeutic measure, compression stockings, for one resident of 20 sampled (Resident 64).

Inspectors wroteBased on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to accurately and consistently assess residents' nutritional status and parameters and timely implement measures to prevent continued weight loss for two of three residents sampled (Resident 75, and 51)

Inspectors wroteBased on a review of select facility policy and clinical records and resident and staff interviews it was determined that the facility repeatedly failed to provide person centered pain management consistent with professional standards of quality by failing to ensure that licensed nurses timely administered a resident's pain medication as scheduled for one of 20 residents reviewed (Resident 64).

Inspectors wroteBased on review of select facility policy and controlled drug records, observation, and staff interview, it was determined that the facility failed to implement pharmacy procedures for the reconciliation of controlled drugs on two of two medication carts reviewed (Med cart A, and D).

Inspectors wroteBased on review of clinical records and staff interview, it was determined that the facility failed to timely consult with the physician regarding a significant weight gain displayed by one resident out of 20 sampled (Resident 55).