Mountain Top Rehabilitation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Mountain Top Rehabilitation & Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF677Feb 20, 2026

  Based 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. […]

• Actual harm, isolatedF686Feb 20, 2026

  Based 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.) Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research &; Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, standardized pressure ulcer risk assessment, and care planning and implementation to… […]

• Actual harm, isolatedF692Feb 20, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF640Apr 18, 2025

  Based 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). […]

• No harm, potential for more than minimal, patternF550Feb 20, 2026

  Based 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). Findings include: During a resident group interview on February 19, 2026, at 10:00 AM, five out of six alert and oriented residents (Residents 19, 58, 64, 80, and 101) indicated that they have concerns about long wait times for care. One out of the six residents in attendance indicated that she is independent and does not need to ring her call bell for staff assistance. […]