Mountain City Rehab Center

F 0580

any change.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Rehab Center

48 Tarn Terrace Frostburg, MD 21532

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to break.A written statement signed by GNA #4, dated 12/17/2024, indicated that she, along with LPN #3, GNA #2, and GNA #5, assisted Resident #4 following the resident's fall out of bed. The statement indicated that she witnessed LPN #3 be mean to Resident #4 and yelled at the resident to stop moving. Per the statement, LPN #3 pulled the resident's arm really hard and yelled at the resident. The statement indicated that LPN also spoke to the resident rudely when the resident was on the floor.An undated written statement signed by GNA #2 indicated that on 12/16/2024, LPN #3 was rude and disrespectful to Resident #4. The statement indicated that the resident had fallen out of bed when she was asked to help GNA #5, GNA #4, and LPN #3 pick the resident up. The statement indicated that she witnessed LPN #3 yell at the resident to stop moving so much and witnessed her pushing, pulling, and jerking [Resident #4] around.A written statement signed by GNA #5, dated 12/17/2024, indicated that she witnessed LPN #3 being rough with Resident #4 after the resident fell out of bed. The statement indicated that LPN #3 yelled at the resident to stop moving. Per the statement, LPN #3 told her that she was so mad that she ripped a blood pressure cuff off the resident and broke it because the resident would not stop moving. The statement indicated that LPN #3 also had a rude attitude towards the resident.During an interview on 10/08/2025 at 1:41 PM, GNA #2 stated LPN #3 pulled on and jerked Resident #4's arms while struggling to remove the resident's t-shirt and obtain the resident's blood pressure. She stated she reported it to LPN #6 because she thought it was abuse. During an interview on 10/08/2025 at 5:30 PM, GNA #4 stated that when she entered Resident #4's room to help GNA #2 and GNA #5 transfer Resident #4 back to bed after the resident's fall, she observed Resident #4 covered in vomit on the floor. GNA #4 stated that they assisted the resident back to bed, and

the resident sat on the edge of the bed. GNA #4 stated that LPN #3 was behind the resident on the bed and stuck her knee against the resident's back while pulling up and she had one of the resident's arms behind them pulling on it also. GNA #4 stated that the other two GNAs and she discussed LPN #3's behavior and believed it to be abuse and reported it to the other nurse on duty. During an interview on 10/20/2025 at 6:15 PM, GNA #5 stated that they found resident #4 on the floor while checking on residents at around midnight and assisted with getting the resident back to bed after the fall. GNA #5 stated that LPN #3 handled Resident #4 roughly by pulling, grabbing, and yelling at the resident in an attempt to have the resident lie still so that the LPN could obtain a blood pressure reading. GNA #5 stated that the three GNAs discussed the incident and agreed it was abuse and then reported it to LPN #6.During an interview on 10/09/2025 at 8:00 PM, LPN #6 stated that as soon as the GNAs reported the alleged abuse, she called her supervisor (the current DON, who was the ADON at the time of the incident) immediately. During an

interview on 10/13/2025 at 1:21 PM, DON stated that they determined that abuse did occur.During

interview on 10/13/2025 at 2:55 PM, the Administrator (ADM) stated that she was not familiar with the incident involving Resident #4 because she was not the Administrator yet at the time of the incident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Rehab Center

48 Tarn Terrace Frostburg, MD 21532

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was called, and the Former DON called the corporate office. RN #32 stated the Former DON called back

after talking with the Regional Director of Operations (RDO). RN #32 revealed the Former DON indicated that the RDO stated the incident was not an altercation. RN #32 stated she told the DON that she did not feel comfortable with that decision and documented what she saw. RN #32 stated the altercation was resident-to-resident abuse, and that was why they got the witness statements and notified the Former DON.

During an interview on 11/07/2025 at 11:23 AM, the DON reviewed the facility's policy about resident-to-resident altercations and agreed that they did not follow their policy in regard to updating the care plan, completing a risk management form at the time of the incident, investigating the incident, and reporting it.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Rehab Center

48 Tarn Terrace Frostburg, MD 21532

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

During an interview on 10/11/2025 at 9:22 AM, the Administrator (ADM) stated that resident-to-resident altercations fell under abuse, which was reportable. Regarding the incident between Resident #13 and Resident #14, the ADM stated that the former DON told her that one resident was trying to help another resident be pushed in their wheelchair, but the resident in the wheelchair did not want to be pushed. The ADM stated that they were informed that the alleged perpetrator never touched the victim, and that staff discouraged the alleged perpetrator who walked away with no concerns. The ADM stated that as described, that incident was not reportable, but if she had all the facts, then she would have reported the incident.

During an interview on 11/07/2025 at 8:28 AM, the ADM stated that she was not in the facility when the incident occurred between Resident #13 and Resident #14 but heard about it in the morning meeting. She stated that she was told that one resident was pushing the other resident in their wheelchair and that resident did not want to be pushed, so they were separated. She stated she was not aware of the resident being grabbed by the collar. She stated that if she had known the details, she would have investigated and reported it at that time.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Rehab Center

48 Tarn Terrace Frostburg, MD 21532

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

standing close to the head of Resident #19's bed and close to Resident #19's tray table. GNA #5 stated she saw Resident #3's hands raised, but she did not see Resident #3's hands directly close to or on Resident #19's neck.

During an interview on 10/09/2025 at 6:31 PM, the former DON stated she vaguely remembered the allegation involving resident-to-resident abuse between Resident #3 and Resident #19. The former DON stated that she would have notified the ADM of the abuse allegation. She stated that she was unable to recall whether the abuse allegation was reported to the state survey agency.

During an interview on 10/13/2025 at 12:21 PM, the facility's current DON stated that the alleged resident-to-resident abuse between Resident #3 and Resident #19 should have been thoroughly investigated to ensure resident safety. The DON stated that there should have been written statements from staff, and Resident #3 and Resident #19 should have been monitored. The DON stated that the investigation would have included identificati

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Rehab Center

48 Tarn Terrace Frostburg, MD 21532

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

include a stage or description. The MDS Coordinator stated she should have clarified the pressure ulcer information with nursing staff so that it could have been coded. The MDS Coordinator acknowledged that

the MDS for Resident #4 was not accurate and did not reflect the resident's actual status which had the potential to affect the resident's care and care planning.During an interview on 11/04/2025 at 2:24 PM, the DON stated that her expectation was for MDS assessments to be coded accurately through coordination with facility staff.During an interview on 11/04/2025 at 2:48 PM, the Administrator (ADM) stated that she expected the MDS staff to assess and code residents accurately as the MDS information affected resident treatment and care planning. The ADM stated MDS assessments should be completed in accordance with

the facility's policy.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Rehab Center

48 Tarn Terrace Frostburg, MD 21532

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm

to give an anticoagulant medication after a fall and to notify the provider for further instructions.During an

interview on [DATE REDACTED] at 8:28 AM, the Administrator stated that documentation should be as accurate as possible and include all critical elements to be able to tell the story of the situation. She stated neurological checks were done to assess brain activity and to assess for complications. She stated she would expect the physician to be notified of any change.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Rehab Center

48 Tarn Terrace Frostburg, MD 21532

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

continent or incontinent, and what kind of shoes the resident had on at the time of the fall. LPN #24 stated witness statements were obtained from assigned staff and the person that found the resident. LPN #24 stated that the assigned nurse was also responsible for the Post Fall Huddle (PFH) Fall Scene Investigation Form. LPN #24 stated she was familiar with Resident #7. LPN #24 stated Resident #7 was a high fall risk, and the resident was not to be left in their room alone when up in their wheelchair, that directive had been communicated to all staff, and she had passed the information to all GNAs on her shift. LPN #24 stated she was sure that GNA #25 was aware not to leave Resident #7 alone in their room when up in the wheelchair since GNA #25 provided care to Resident #7 daily. LPN #24 stated that the visual cues in Resident #7's room (initiated as an intervention on 07/08/2024 and 09/12/2024) were of no benefit to the resident since

the resident was independent and thought they could still stand. LPN #24 stated Resident #7 was unable to comprehend the visual cues, and she had discussed the lack of comprehension with other staff. LPN #24 stated that using education or reminders for Resident #7 (initiated as an intervention on 09/19/2024) was not an effective intervention since the resident had impaired memory. LPN #24 stated Resident #7's roommate tried to take care of Resident #7, which aggravated the resident and would make Resident #7 try to get up and away from the roommate. LPN #24 stated she had communicated that concern to the Assistant Director of Nursing (ADON), the former Director of Nursing (DON), and the current DON. The LPN stated that even after telling the administrative nurses, no one had mentioned changing the resident's room to decrease the aggravation.

During an interview on 10/10/2025 at 11:18 AM, LPN #10 stated the nurses' station was not always staffed, and if the nurses had to administer mediations, they asked the GNAs to keep eyes on the residents. LPN #10 stated Resident #7 should never be left alone in their wheelchair because they would attempt to walk.

Registered Nurse (RN) #26 was interviewed on 10/08/2025 at 3:05 PM. RN #26 stated that it was important to fully complete an incident report so leadership would know what caused the fall, and so they could choose interventions to prevent further falls.

RN #27 was interviewed on 10/10/2025 at 2:06 PM and stated that in addition to a physical assessment

after a fall, she was expected to ask the resident what happened to make them fall. RN #27 stated that if

the res

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Rehab Center

48 Tarn Terrace Frostburg, MD 21532

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865

Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or potential for actual harm

Based on facility document review and interview, the facility failed to ensure their Quality Assurance Performance Improvement (QAPI) program effectively implemented a plan to address quality deficiencies identified related to falls. This deficient practice affected 3 (Residents #7, 12, and #18) of 9 sampled residents reviewed for accidents during the complaint survey.Findings included:The facility's QAPI meeting documentation from June 2025 to September 2025 indicated that falls were reviewed each of the months.

The documents revealed that in May, the facility documented that there were 25 falls with 22 residents and that two of the residents accounted for five of the falls. A review of the facility's documents revealed no evidence of corrective actions being developed to address the concern nor evidence of a good faith effort to address the concerns.During an interview on 10/15/2025 at 3:54 PM, Registered Nurse (RN) #26 stated that she had never been to a QAPI meeting and had never been asked to contribute to a performance improvement project (PIP). She stated that there were papers that listed falls by shift at the nurses' station, but no one had asked for her opinion or suggestions on how to decrease falls.During an interview on 10/15/2025 at 4:00 PM, Licensed Practical Nurse (LPN) #38 stated that she had never been asked to participate in QAPI. She stated that she had been asked for suggestions to decrease falls on the secured unit for specific residents, but not in development of a PIP with goals and outcomes.During an interview on 10/15/2025 at 11:14 AM, the Director of Nursing (DON) stated that falls had been identified as a concern and were being discussed in QAPI meetings. She stated that there was a weekly fall meeting with administrative staff and the interdisciplinary team (IDT) and discussion in morning meetings where the facility staff reviewed risk incident reports. She stated that for an identified concern, she expected a written action plan that showed the identified problem and ways the facility was trying to fix it, with tools like audits, metrics to meet, and ways to determine if interventions were effective. She stated that if one was drafted somewhere, she was not involved in the follow up or action items.The Administrator (ADM) was interviewed

on 10/11/2025 at 9:50 AM. The ADM stated that she noticed falls were high about six months prior, when

she first started at the facility. She stated that one intervention discussed included frequent and constant rounds, but she ran into push back from the former DON (in the position at the time of the discussion of frequent and constant rounds). She stated that the standard was two hours, but she expected more. She stated that the corrective action plan for falls was verbally relayed to staff, but there was no written plan.

She stated her main focus related to falls was to reduce the number of falls and then when the numbers of falls started declining, the plan was to assess other parts of the fall policy to see if there were other issues.

She stated staff did daily angel rounds, which were documented where department managers were to discuss what they had found, including any fall risks identified.During a follow up interview on 10/15/2025 at approximately 12:00 PM, the ADM stated that her expectation for an identified concern with falls for QAPI was for there to be a plan. She stated that they needed to talk about the concern and put interventions in place. In regard to whether there should be a written plan with steps to follow and tools to measure effectiveness, the ADM stated that she expected the fall protocol to be followed and to change things that did not work. The ADM stated that if the falls continued to happen, then they would try a new intervention. In regard to how staff tracked interventions the facility had tried, she stated they discussed the concern in morning meetings and made corrections on an individual basis. She stated that they were implementing angel rounds and increased monitoring facility wide.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet