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🔎 Mountain City Nursing And Rehabilitation Center

Inspection Results


Inspection Overview

Mountain City Nursing And Rehabilitation Center has been cited for a total of 67 deficiencies since we began saving each survey.

In Pennsylvania, the average facility has **42.85 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

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.

Survey Date: 2025-02-07
Correction Date: 2025-03-27
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2025-02-07
Correction Date: 2025-03-31
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2025-02-07
Correction Date: 2025-03-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2025-02-07
Correction Date: 2024-09-02
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2025-02-07
Correction Date: 2025-03-27
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2025-02-07
Correction Date: 2025-03-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2025-01-03
Correction Date: 2025-03-27
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-07-10
Correction Date: 2024-07-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2024-07-10
Correction Date: 2024-07-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-07-10
Correction Date: 2024-07-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2024-07-10
Correction Date: 2024-07-29
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2024-07-10
Correction Date: 2024-07-29
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2024-05-31
Correction Date: 2024-07-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-05-31
Correction Date: 2024-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: K

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-05-31
Correction Date: 2024-07-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Survey Date: 2024-05-31
Correction Date: 2024-07-10
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Survey Date: 2024-05-31
Correction Date: 2024-07-10
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: E

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2024-05-31
Correction Date: 2024-07-10
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: H

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-04-19
Correction Date: 2024-07-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide care or services that was trauma informed and/or culturally competent.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Survey Date: 2024-04-19
Correction Date: 2024-07-10
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2024-03-20
Correction Date: 2024-04-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2024-03-20
Correction Date: 2024-07-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-11-21
Correction Date:
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-11-21
Correction Date:
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-09-28
Correction Date: 2023-09-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2023-09-28
Correction Date: 2023-10-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Survey Date: 2023-09-28
Correction Date: 2023-10-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2023-09-06
Correction Date: 2023-10-17
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-09-06
Correction Date: 2023-10-17
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-09-06
Correction Date: 2023-10-17
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-06-21
Correction Date: 2023-06-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2023-05-12
Correction Date: 2023-06-08
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2023-05-12
Correction Date: 2023-06-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-05-12
Correction Date: 2023-06-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2023-05-12
Correction Date: 2023-06-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2023-05-12
Correction Date: 2023-06-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2023-05-12
Correction Date: 2023-06-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2023-05-12
Correction Date: 2023-06-08
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-05-12
Correction Date: 2023-06-08
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-07-15
Correction Date: 2022-08-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-07-15
Correction Date: 2022-08-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Have policies on smoking.

Survey Date: 2022-07-15
Correction Date: 2022-08-10
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2022-07-15
Correction Date: 2022-08-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2022-07-15
Correction Date: 2022-08-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-07-15
Correction Date: 2022-08-10
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2021-09-03
Correction Date: 2021-10-13
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2021-09-03
Correction Date: 2021-10-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2021-09-03
Correction Date: 2021-10-13
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-09-03
Correction Date: 2021-10-13
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2021-04-30
Correction Date: 2021-05-21
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Survey Date: 2021-04-30
Correction Date: 2021-05-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-04-30
Correction Date: 2021-05-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2021-04-30
Correction Date: 2021-05-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2021-04-30
Correction Date: 2021-05-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2021-04-30
Correction Date: 2021-04-30
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2021-01-27
Correction Date: 2021-01-27
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2021-01-27
Correction Date: 2021-02-17
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**