Mountain City Nursing & Rehabilitation Center

F-F600

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 395582 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395582 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Nursing & Rehabilitation Center 403 Hazle Township Boulevard Hazleton, PA 18202

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 0867 28 Pa. Code 211.12 (c) Nursing services

Level of Harm - Minimal harm or 28 Pa. Code 201.18(e)(3)(4) Management potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 395582

F-F726

28 Pa. Code 201.18 (e)(1) Management

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

28 Pa. Code 201.29 (a)(c)Resident Rights

28 Pa. Code 201.14(a) Responsibility of Licensee

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 395582 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395582 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Nursing & Rehabilitation Center 403 Hazle Township Boulevard Hazleton, PA 18202

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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21738

Residents Affected - Some Based on observation, review of select facility incident reports and clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision and maintain an environment free of accident hazards to prevent a minor injury (a cut to the thumb) sustained by one of 11 sampled residents (Resident 65).

Findings include:

A review of clinical record revealed that Resident 65 was admitted to the facility on [DATE REDACTED], with diagnoses which included chronic alcoholism and hypertension.

A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated June 10, 2024, indicated the resident was moderately cognitively impaired with a BIMS (brief screener that aids in detecting cognitive impairment) score of 8 (a score of 8-12 indicates moderate cognitive impairment).

A review of the resident's current care plan revealed that the resident did have a self-care deficit and required the assistance of one staff for bathing and was independent for ambulation and toileting.

A facility incident report dated July 3, 2024, at 6:35 PM revealed that the resident sustained a cut to his right thumb. The resident was found standing at the medication cart holding multiple used razors. The resident stated that he had to dig them out in the shower room. The resident sustained a cut measuring 1.0 cm x 0.2 cm with a scant amount of dried blood. Resident washed hands with antibacterial soap. Right thumb flushed with normal saline and patted dry. Physician and Resident Representative notified. New physician order to cleanse right thumb with normal saline solution, apply triple antibiotic ointment, and band aid daily. STAT {immediate} CBC, BMP, and Hepatitis Panel were ordered. Tdap Vaccine ordered. Resident placed on increased supervision. All Sharps containers (container used for disposal of used needles and other sharps to reduce risk of harm to others) were checked and changed as necessary. Sharps containers were removed from the shower rooms.

During an onsite survey on July 9, 2024, at 2:05 PM observations were conducted on the third floor which revealed the following potential accident hazards

-the sharps container was removed from the wall, but the mounted encasement that previously held the sharps container remained on the shower wall, and a razor was observed in the hollow case allowing for access of the sharp object by just placing a hand inside

-this same situation was observed in the third floor bathroom of the lounge area. The sharps container was removed from the wall, but the mounted encasement that previously held the sharps container remained on

the wall, and a razor was observed in the hollow case allowing for access of the sharp object by just placing

a hand inside

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 395582 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395582 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Nursing & Rehabilitation Center 403 Hazle Township Boulevard Hazleton, PA 18202

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 - observation in room [ROOM NUMBER]'s bathroom revealed no sharps container, but the encasement, that previously held the container, contained two razors that were easily accessible by placing a hand inside in Level of Harm - Minimal harm or the case. potential for actual harm

Observation on the second floor nursing unit revealed two razors in the encasement receptacle, that Residents Affected - Some previously held the sharps container, mounted on the wall of the shower room. The director of nursing stated

the facility removed the sharps container from the boxes that held them to the walls but staff continued to place the razors in that box which allowed continued access to the sharp items they contained.

Interview with the director of nursing on July 9, 2024, at approximately 2:30 PM failed to provide evidence

the facility provided adequate supervision and maintained an environment free of accident hazards to prevent injury to Resident 65.

28 Pa. Code 211.12 (d)(5) Nursing services.

28 Pa. Code 201.18 (e)(2.1) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 395582 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395582 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Nursing & Rehabilitation Center 403 Hazle Township Boulevard Hazleton, PA 18202

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 0726 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. Level of Harm - Minimal harm or potential for actual harm 13456

Residents Affected - Some Based on review of select facility policy and staff interview, it was determined the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to conduct a thorough resident assessment of residents following an incident of sexual abuse involving two out of 11 residents reviewed (Resident 16 and Resident 91)

Findings include:

A review of the facility's policy entitled Pennsylvania Resident Abuse last reviewed by the facility August 2023, indicated that after an allegation of sexual abuse The resident's attending physician should be notified if an incident has occurred requiring physician involvement. If appropriate, the facility should send the resident to the hospital for an examination.

The facility will contact the police for any allegation of misappropriation of resident property. Administrator or designee will notify police when the facility receives a complaint of, or suspect sexual abuse, serious bodily injury or suspicious death in Allegations of Sexual Abuse every effort will be made to preserve evidence on both the resident and the perpetrator.

The facility policy included the following procedures to be implemented for both the resident victim and the perpetrator:

Will not be bathed or cleaned

Will not receive incontinence care

Incontinence brief will not be changed

Clothing will not to be changed

No oral care will be provided

Both resident and perpetrator will be evaluated in the ER.

Linens will be bagged and provided as evidence, if applicable

Police to be notified

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 395582 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395582 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Nursing & Rehabilitation Center 403 Hazle Township Boulevard Hazleton, PA 18202

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 0726 A review of nursing documentation in Resident 16's clinical record, dated July 6, 2024 at 10:13 PM, written by Employee 2 an RN, revealed that Aide came to LPN stating she walked in on resident (Resident 16} and Level of Harm - Minimal harm or another resident {91} having sex. This RN went to their rooms. At this point each resident was in their potential for actual harm separate rooms. The male resident {Resident 91} said that the female resident was naked and motioning for him to come over {to her room}. Once the male resident came over they started to engage in sex. Once the Residents Affected - Some aide came in with the meal tray they stopped and he went back to their separate rooms. The female resident {Resident 16} stated that she doesn't remember a guy being here and if there was a guy here it would be {Resident 16's boyfriend name} Administrator, DON and family was notified. The physician was notified, the family declined any medical treatment at the hospital. Agency of Aging was notified at 8:11 PM. The police were notified at 8:21 PM. The police came in and did an investigation and talked to both parties. Head to toe assessment was completed on both residents. There is no history of either of the resident conversing prior to this. The male resident {Resident 91} continues to be on 1:1 until tomorrow. She {Resident 16} is moving to white building in a different room.

Employee 2 wrote an identical entry in Resident 91's medical record.

Further review of Resident 16's clinical record revealed nursing documentation entitled Focused Head to Toe

Observation regarding sexual occurrence dated July 6, 2024 at 7:46 PM. Employee 2 did not document the results of an examination an examination of the resident's mouth, anus, or genital areas.

The residents were not sent to the hospital for evaluation according to facility policy.

During a telephone interview with Employee 2, RN, on July 9, 2024, at 12:52 PM she stated that she completed the head to toe assessment on Resident 16. However, she verified that she did not document that

she examined Resident 16's mouth, anus, or genitalia and did not obtain orders to complete bloodwork to rule out sexually transmitted diseases She confirmed that she had not performed a sexual assault examination on Resident 16 and confirmed that she is not trained to conduct that type of examination. When asked about preservation and collection of evidence, she stated the bed linens should be washed. Employee 2 stated that she was unsure what was done with the residents' bedding and clothing. Employee 2 also confirmed she did not complete or document any assessment of Resident 91.

As per the International Association of Forensic Nurses, a healthcare provider trained to conduct sexual assault exams performs a sexual assault exam. A sexual assault forensic examiner (SAFE), a sexual assault nurse examiner (SANE), or one of these types of doctors.

A review of Employee 2's records revealed that she was not trained to conduct a sexual assault forensic exam.

The DON and NHA confirmed during interview on July 9, 2024, that the residents were not sent to the hospital according to facility policy and Employee 2, RN, did not possess the necessary competencies to perform a sexual assault exam and she was not specifically trained to perform that type of sexual examination on the residents to include mouth, anus and genitalia.

28 Pa. Code 211.10 (a)(d) Resident care policies

28 Pa. Code 211.5 (f)(ii) (iii) (iv)Medical records

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 395582 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395582 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Nursing & Rehabilitation Center 403 Hazle Township Boulevard Hazleton, PA 18202

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 0726 28 Pa. Code: 201.18 (e)(1) Management.

Level of Harm - Minimal harm or 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services. potential for actual harm 28 Pa. Code 201.19 (1)(3) Personnel records Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 395582 Department of Health & Human Services Printed: 09/18/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395582 B. Wing 07/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain City Nursing & Rehabilitation Center 403 Hazle Township Boulevard Hazleton, PA 18202

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 21738

Residents Affected - Some Based on review of the facility's plan of correction from the survey of April 19, 2024, and the findings of the survey ending July 10, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent a continued quality deficiency related to abuse prohibition to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies.

Findings include:

During a standard survey completed at the facility on April 19, 2024, deficient facility practice was identified under the requirement for residents to be free from abuse and neglect. In response to this quality deficiency

the facility developed a plan of correction, to include a quality assurance monitoring component to ensure that solutions were sustained. This plan was to be completed by May 14, 2024.

In response to the quality of care deficiency cited during the survey of April 19, 2024, related to the facility's failure to prevent resident abuse the facility's plan of correction was to:

Educate facility staff (interdisciplinary) on identifying behaviors and placing interventions to reduce initiating and/or receiving physical aggression.

To prevent abuse from reoccurring, the nursing home administrator (NHA)/designee educated staff on the Abuse Policy.

To monitor and maintain ongoing compliance, the director of nursing (DON)/designee reviewed progress notes five times per week times four weeks then monthly times two to identify any residents exhibiting aggressive behaviors. To monitor and maintain ongoing compliance, the DON/designee reviewed progress notes five times per week for four weeks then monthly times two to identify residents having increased behaviors that put them at risk for receiving aggression. To monitor and maintain ongoing compliance the DON/designee interviewed five interviewable residents weekly times four then monthly times two to ensure

they feel safe in the facility. To monitor and maintain ongoing compliance, the DON/designee will review resident to resident incidents weekly times four then monthly times two to establish patterns of day of the week and shift.

However, during the revisit survey ending July 10, 2024, a review clinical records, facility incident reports, and staff interviews revealed that the facility failed to ensure that one resident (Resident 106) was free from physical abuse and one resident (Resident 16) was free from sexual abuse and resultant psychosocial harm out of 11 sampled residents.

The facility's quality assurance monitoring plans failed to identify the ongoing quality deficiency and sustain solutions to the identified quality deficiency to be free from abuse and neglect.

Refer