Cycle 1
Health 2025-04-16 · Fire 2025-04-16
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
19 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cincinnati, OH
The Chateau At Mountain Crest Nursing & Rehab Ctr
1-star overall rating with 1-star inspections with $174,018 in total fines with 16 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
2586 Lafeuille Avenue, Cincinnati, OH
(513) 662-2444
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
167
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,194
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.83
Performance 56.20% · Measure score 1.83 · Achievement 1.83 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.71
Baseline 3.04 hours · Performance 3.57 hours · Measure score 1.71 · Achievement 1.71 · Improvement 1.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.99% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 12% · Lower 95% interval 6.67% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 228 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 55.8% |
92.4%
36.6 pts worse
|
93.4%
37.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.6% · Q2 63.6% · Q3 64.7% · Q4 42.9% · 4Q avg 55.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 66.4% |
94.5%
28.1 pts worse
|
95.5%
29.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 66.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 1.7% · Q4 0.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
26.1%
24.7 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 1.0% · Q4 1.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
6.2%
2 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.3% · Q3 14.5% · Q4 6.6% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.4% |
25.4%
1 pts worse
|
19.6%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 24.3% · Q3 29.7% · Q4 29.0% · 4Q avg 26.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.3% |
11.5%
21.8 pts worse
|
16.7%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 32.0% · Q3 33.3% · Q4 33.3% · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.3% |
7.7%
3.4 pts better
|
16.3%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 6.8% · Q3 0.0% · Q4 0.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
6.2%
2.6 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.4% · Q3 1.9% · Q4 1.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.2%
0.5 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
0.5%
0.3 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.7% |
21.7%
9 pts better
|
19.8%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.2% · Q3 16.2% · Q4 10.0% · 4Q avg 12.7% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
3.7%
About the same
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.8% · Q3 3.2% · Q4 5.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 3.1% |
78.1%
75 pts worse
|
81.7%
78.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 5.0% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 10.7% |
1.2%
9.5 pts worse
|
1.6%
9.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 10.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 12.0% |
75.6%
63.6 pts worse
|
79.7%
67.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 12.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-01 · Fire 2022-12-01
30 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2019-10-28 · Fire 2019-10-28
28 health deficiencies
Top issue: Resident Rights (7 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-16
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-04-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-04-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-12
F · Potential for more than minimal harm
2025-04-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-04-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-16
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-04-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-04-16
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-06-12
E · Potential for more than minimal harm
2025-04-16
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-07-17
F · Potential for more than minimal harm
2024-01-18
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-01-30
F · Potential for more than minimal harm
2024-01-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-30
F · Potential for more than minimal harm
2024-01-18
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-01-30
F · Potential for more than minimal harm
2024-01-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-30
F · Potential for more than minimal harm
2022-12-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-24
F · Potential for more than minimal harm
2022-12-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-02-21
F · Potential for more than minimal harm
2022-12-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-21
F · Potential for more than minimal harm
2022-12-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-21
F · Potential for more than minimal harm
2022-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-24
F · Potential for more than minimal harm
2022-12-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-21
F · Potential for more than minimal harm
2022-12-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-21
F · Potential for more than minimal harm
2022-12-01
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-24
F · Potential for more than minimal harm
2022-12-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-24
F · Potential for more than minimal harm
2022-12-01
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-01-24
F · Potential for more than minimal harm
2022-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-21
E · Potential for more than minimal harm
2022-12-01
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-02-21
E · Potential for more than minimal harm
2022-12-01
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-01-24
E · Potential for more than minimal harm
2022-12-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-01-24
E · Potential for more than minimal harm
2022-12-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-24
E · Potential for more than minimal harm
2022-12-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-01-24
E · Potential for more than minimal harm
2022-12-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-24
E · Potential for more than minimal harm
2022-12-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-21
E · Potential for more than minimal harm
2022-12-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-02-21
E · Potential for more than minimal harm
2022-12-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-24
E · Potential for more than minimal harm
2022-12-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-24
F · Potential for more than minimal harm
2019-10-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-11
E · Potential for more than minimal harm
2019-10-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-03-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2026-01-23
E · Potential for more than minimal harm
2025-06-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-06-12
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-07-17
F · Potential for more than minimal harm
2025-04-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-07-17
E · Potential for more than minimal harm
2025-04-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-04-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-07-17
D · Potential for more than minimal harm
2025-04-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-04-16
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-04-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-04-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-04-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-04-16
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-04-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-04-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-01
E · Potential for more than minimal harm
2025-01-30
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-30
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-10-30
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-18
G · Actual harm
2024-09-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-09-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-09-03
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-03
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-09-03
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-10-23
G · Actual harm
2024-06-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-06-21
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2024-07-06
E · Potential for more than minimal harm
2024-01-23
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-01-30
D · Potential for more than minimal harm
2023-09-11
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-05-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-08
D · Potential for more than minimal harm
2023-05-04
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-08
G · Actual harm
2023-04-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-08
G · Actual harm
2022-12-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-26
F · Potential for more than minimal harm
2022-12-01
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-01-26
F · Potential for more than minimal harm
2022-12-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-01
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-01
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-01
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-01
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-01-26
C · Minimal harm
2022-12-01
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2022-12-23
C · Minimal harm
2022-12-01
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-12-23
C · Minimal harm
2022-12-01
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-12-23
C · Minimal harm
2022-12-01
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2022-12-23
C · Minimal harm
2022-12-01
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-12-23
F · Potential for more than minimal harm
2019-10-28
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-03-11
F · Potential for more than minimal harm
2019-10-28
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2020-03-11
E · Potential for more than minimal harm
2019-10-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2020-03-11
E · Potential for more than minimal harm
2019-10-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-03-11
E · Potential for more than minimal harm
2019-10-28
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2020-03-11
E · Potential for more than minimal harm
2019-10-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-11
E · Potential for more than minimal harm
2019-10-28
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2020-03-11
E · Potential for more than minimal harm
2019-10-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-11
E · Potential for more than minimal harm
2019-10-28
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-11
D · Potential for more than minimal harm
2019-10-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-11
Penalties and ownership
What sits behind the stars
$0
2025-04-16
Payment Denial
Payment Denial · denial start 2025-07-16 · 1 days
1 day denial
$119,655
2024-09-03
Fine
Fine · fine $119,655
Fine
$0
2024-09-03
Payment Denial
Payment Denial · denial start 2024-09-28 · 51 days
51 day denial
$39,683
2024-06-21
Fine
Fine · fine $39,683
Fine
$14,680
2023-04-25
Fine
Fine · fine $14,680
Fine
$0
2023-04-25
Payment Denial
Payment Denial · denial start 2023-05-19 · 20 days
20 day denial
Ownership
Mff Mountain Crest Holdco, LLC
5% Or Greater Direct Ownership Interest · Organization
Bowman, Tara
Operational/Managerial Control · Individual
Bowman, Tara
W-2 Managing Employee · Individual
Cooley, David
Operational/Managerial Control · Individual
Flanagan, Michael
5% Or Greater Indirect Ownership Interest · Individual
Flanagan, Michael
Corporate Officer · Individual
Mff Management, LLC
5% Or Greater Indirect Ownership Interest · Organization
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#3
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