ElderGrade

Inspection citations at Mountain City Nursing & Rehabilitation Center

51 citations on record, 5 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 1 1
2025 9 0
2024 25 4
2023 16 0
G January 12, 2026 Tag F0689 Complaint investigation Corrected Jan 2026

Quality of Life and Care Deficiencies

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

Actual harm to a resident

D March 27, 2025 Tag F0867 Complaint investigation Corrected Mar 2025

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

D March 27, 2025 Tag F0600 Complaint investigation Corrected Mar 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

D February 7, 2025 Tag F0883 Corrected Mar 2025

Infection Control Deficiencies

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

No actual harm, potential for more than minimal harm

D February 7, 2025 Tag F0842 Complaint investigation Corrected Mar 2025

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

D February 7, 2025 Tag F0689 Corrected Sep 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D February 7, 2025 Tag F0641 Corrected Mar 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

E February 7, 2025 Tag F0600 Corrected Mar 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

E February 7, 2025 Tag F0585 Corrected Mar 2025

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D January 3, 2025 Tag F0692 Complaint investigation Corrected Mar 2025

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E July 10, 2024 Tag F0867 Complaint investigation Corrected Jul 2024

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

E July 10, 2024 Tag F0726 Complaint investigation Corrected Jul 2024

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

E July 10, 2024 Tag F0689 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E July 10, 2024 Tag F0607 Complaint investigation Corrected Jul 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

G July 10, 2024 Tag F0600 Complaint investigation Corrected Jul 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Actual harm to a resident

D May 31, 2024 Tag F0809 Complaint investigation Corrected Jul 2024

Nutrition and Dietary Deficiencies

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.

No actual harm, potential for more than minimal harm

D May 31, 2024 Tag F0677 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D May 31, 2024 Tag F0550 Complaint investigation Corrected Jul 2024

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

E May 31, 2024 Tag F0835 Complaint investigation Corrected Jul 2024

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

G May 31, 2024 Tag F0805 Complaint investigation Corrected Jul 2024

Nutrition and Dietary Deficiencies

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

Actual harm to a resident

K May 31, 2024 Tag F0689 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

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

Immediate jeopardy to resident health or safety

D April 19, 2024 Tag F0835 Corrected Jul 2024

Administration Deficiencies

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

No actual harm, potential for more than minimal harm

D April 19, 2024 Tag F0760 Corrected Jul 2024

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

D April 19, 2024 Tag F0699 Corrected Jul 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D April 19, 2024 Tag F0561 Corrected Jul 2024

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0838 Corrected Jul 2024

Administration Deficiencies

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.

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0744 Corrected Jul 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0741 Corrected Jul 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0695 Corrected Jul 2024

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0585 Corrected Jul 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0584 Corrected Jul 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

F April 19, 2024 Tag F0812 Corrected Jul 2024

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

H April 19, 2024 Tag F0600 Corrected Jul 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Actual harm to a resident

E March 20, 2024 Tag F0584 Complaint investigation Corrected Jul 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

E March 20, 2024 Tag F0550 Complaint investigation Corrected Apr 2024

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

E November 21, 2023 Tag F0656 Complaint investigation Corrected Dec 2023

Resident Assessment and Care Planning Deficiencies

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

No actual harm, potential for more than minimal harm

E November 21, 2023 Tag F0550 Complaint investigation Corrected Dec 2023

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

D September 28, 2023 Tag F0626 Complaint investigation Corrected Oct 2023

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

D September 28, 2023 Tag F0622 Complaint investigation Corrected Oct 2023

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D September 28, 2023 Tag F0600 Complaint investigation Corrected Sep 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.