Pennsylvania Department of Health
MOUNTAIN TOP REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MOUNTAIN TOP REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are 119 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


MOUNTAIN TOP REHABILITATION & HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on May 30, 2025, it was determined that Mountain Top Rehabilitation and Healthcare Center corrected the federal deficiencies cited during the survey of April 18, 2025, under 42 CFR Part 483 Subpart B Requirements for Long Term Care but failed to correct deficiencies cited during the survey of April 2, 2025, and continued to be out of compliance under the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:
Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 2 shifts out of 6 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:11 on the evening shift based on the facility's census.

May 28, 2025 - 8.30 nurse aides on the evening shift, versus the required 9.36 for a census of 103.
May 29, 2025 - 7.73 nurse aides on the evening shift, versus the required 9.27 for a census of 102.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Director of Nursing on May 30, 2025, at 1:00 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.

Plan of Correction - To be completed: 06/05/2025

1.The facility cannot retroactively correct nurse aide staffing ratio.
2. Director of Nursing or designee will conduct an initial audit of the past two weeks scheduled to determine if ratio met compliance.
3. Director of Nursing or designee will re-educate the nursing scheduler on the proper ratio. The facility will hold labor meetings Monday-Friday to validate ratio is accurate and within compliance. During these meetings the facility will review upcoming schedules to validate adequate staffing. Facility will audit each shift to determine the needs for the shift to have adequate staffing.
4. Director of Nursing or designee will conduct random audits of facility ratio weekly for four weeks, then monthly for two months thereafter to verify proper ratio hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary
5. Facility is the site of CNA training. Students will be offered positions within the facility. 4 Students have accepted positions with the facility. Open positions posted on Indeed and various job posting sites. Recruitment efforts using Indeed and other job posting sites with sign on bonus offered when warranted.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:
Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:
May 28, 2025 - 3.02 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the dates noted above.

An interview with the Director of Nursing on May 30, 2025, at 1:00 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 06/05/2025

1. The facility cannot retroactively correct staffing PPD.

2. Director of Nursing or designee will conduct an initial audit of the past two weeks scheduled to determine if PPD met compliance.

3. Director of Nursing or designee will re-educate the nursing scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to validate PPD is accurate and within compliance. During these meetings the facility will review upcoming schedules to validate adequate staffing. Facility will audit each shift to determine the needs for the shift to have adequate staffing.

4. Director of Nursing or designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.
5. Facility is the site of CNA training. Students will be offered positions within the facility. 4 Students have accepted positions with the facility. Open positions posted on Indeed and various job posting sites. Recruitment efforts using Indeed and other job posting sites with sign on bonus offered when warranted.

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