Mountain Top Rehabilitation & Healthcare Center

During an observation on February 18, 2026, at 12:15 PM, Resident 58 was observed ambulating in her room. On the bedside table the Trelegy inhaler and the deep-sea nasal solution and a tube of hydrocortisone cream 1% was observed. An interview with Resident 58 conducted at the time of observation revealed the staff leave her medications for her and when she is finished, she walks the medication back to the medication cart so the medication can be stored.

The interview revealed the hydrocortisone cream was given to the resident from her dermatologist and that she does not return the cream to the cart, that it is always at her bedside and she uses it on her skin when she feels she needs to. A clinical record review failed to reveal documented evidence indicating Resident 58 was assessed and deemed clinically appropriate and safe to self-administer her own medications. In addition, the clinical record did not reveal an order for hydrocortisone cream 1%. A review of the clinical record did not reveal any outpatient visits that could confirm an order for the hydrocortisone cream.

During an interview on February 18, 2026, at 1:30 PM, with Employee 6, Registered Nurse, it was confirmed Resident 58 did not have an active order to self-administer medication.

The interview revealed the resident should not have had the medications left at the bedside and did not have an active order for self-administration of medication. An interview with the Director of Nursing conducted on February 19, 2026, at 10:00AM reviewed the above findings of the facility's failure to assess Resident 58 to ensure she could safely self-administer medications as required in the facility policy. 28 Pa Code: 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.10 (c) Resident care policies. 28 Pa Code 211.12 (d)(1)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

The facility failed to maintain consistent, accurate, and complete documentation of residents' resuscitation preferences across care plans, physician orders, and POLST forms. 28 Pa.

Code 201.29(a) Resident rights. 28 Pa.

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

Code 211.5 (f)(i) Medical records. 28 Pa.

Code 211.12 (d)(1)(3)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

Observation of the Unit 2 shower room on February 18, 2026, at 11:40 AM revealed a faded, heavily worn floor with a 14 inch by 7 inch black oval area on the floor leading into the shower stall and peeled paint on the floor of the shower stall (first stall located closest to the entry door of the shower room).

There was a two inch by one inch piece of plastic laminate missing from the front corner of the sink area in the shower room.

Observation of the Unit 1 shower room on February 18, 2026 at 1:30PM revealed the shower floor to have a build up of what appeared to be soap scum on the shower floor, the shower floor was observed to be lined with anti-slip strips black in color, with a total of 14 strips in place, 7 of the 14 strips were lifted on the sides and not intact.

The anti-slip strips appeared to be worn and not in place, defeating the purpose of the anti-slip action.

Two of the strips appeared to have black hair attached to the sides of the strips that were lifting up. An observation of the bariatric shower bed (a padded bed used to assist in showering dependent bariatric/large residents) located in the Unit 1 bathroom revealed the shower bed was dry and visibly not in use, the shower bed was observed to have a buildup of powder in the corners of the bed.

Interview with the Nursing Home Administrator (NHA) on February 18, 2026, at 2:00 PM confirmed the black on the floor was an epoxy (resin and hardener used as a protective coating on floors) that was used to repair the floor in the past, did not match the floor color, and was not applied in a manner to maintain a homelike interior The NHA confirmed the facility's environment should be kept in good repair and maintained in a clean and homelike manner.

Interview with the Director of Nursing on February 19, 2026, at 10:00 AM reviewed the above findings of the facility's failure to ensure both shower rooms were homelike, clean, and maintained. 28 Pa Code 201.18(e)(2.1) Management

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

During an interview on February 19, 2026, at 12:45 PM, the Director of Nursing confirmed the facility investigation determined Employee 8 did not follow Resident 34's care plan requiring assistance of two staff members for bed mobility.

The Director of Nursing confirmed Employee 8 was immediately removed from the staffing schedule pending investigation and subsequently reassigned to a transportation position without direct resident care responsibilities.

The deficient practice was cited as past noncompliance, The facility implemented corrective actions immediately following the incident.

The resident was assessed and transferred for medical evaluation.

Employee 8 was immediately suspended pending investigation outcome.

The facility reviewed all residents' records to confirm current bed mobility assistance levels and ensure care plans and Kardex entries accurately reflected required assistance levels.

The facility completed skin inspections for residents requiring two-person assistance with bed mobility.

Nursing staff received re-education on adherence to individualized care plans and the facility's Abuse and Neglect policy. To sustain compliance, nursing administration initiated random audits of five resident care interactions to verify that staff performed bed mobility according to individualized care plans and Kardex instructions.

Audits were conducted daily for one week, biweekly for two weeks, and weekly for one month.

Audit results were reported to the facility's Quality Assurance and Performance Improvement Committee for review and follow-up.

The facility achieved compliance with this requirement on September 24, 2025.

This deficiency is cited as past noncompliance. 28 Pa.

Code 201.14 (a) Responsibility of licensee. 28 Pa.

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

Code 201.29 (a) Resident rights. 28 Pa.

Code 211.10 (c) Resident care policies. 28 Pa.

Code 211.12 (d)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

During an interview on February 20, 2026, at approximately 11:30 AM, the nursing home administrator was unable to provide documented evidence that Resident 98 and their representatives, as applicable, were notified of the reasons for the transfers on the aforementioned date. 28 Pa.

Code 201.14(a) Responsibility of licensee.

central venous catheter (a thin, flexible tube that is inserted into a large vein to the heart to deliver

inserted into a large vein to the heart to deliver medications and other therapies into the bloodstream)

directed to give Ampicillin (an antibiotic medication) 2 gm intravenously (IV, through a vein) every six hours until [DATE], for a bacterial infection due to a right knee prosthetic infection. A review of Resident 3's comprehensive plan of care, initiated on [DATE], and most recently revised on February 13, 2026, failed to include updated goals, interventions, or monitoring related to the resident's PICC line and IV antibiotic therapy.

Following surveyor inquiry, Resident 3's care plan was updated to reflect the resident's current plan of care related to oxygen therapy, PICC line therapy, anticoagulant therapy, code status, diabetes and insulin therapy, and fluid restriction on February 19, 2026.

During an interview on February 19, 2026, at 2:00 PM the Director of Nursing confirmed the facility failed to review and revise Resident 3's care plan to accurately reflect the resident's current medical condition, risks, and required treatments. 28 Pa.

Code 211.12(d)(3)(5) Nursing services

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations.

The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

Review of the facility policy titled Administering Medications last reviewed by the facility on February 2, 2026, revealed that medications are administered as prescribed and in a safe and timely manner.

Medications are administered in accordance with prescriber orders. A clinical record review revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (stroke, caused by disrupted blood flow to the brain) and left sided hemiplegia (paralysis or severe weakness on the left side of the body).

Review of a physician's order dated December 5, 2025, revealed an order for Midodrine HCL (hydrochloride) 5 mg one tablet via PEG tube (Percutaneous endoscopic gastrostomy is an endoscopic medical procedure in which a tube is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) before meals for hypotension, hold medication for systolic blood pressure greater than 100 mmHg (systolic blood pressure is the top number in the blood pressure reading representing the pressure in the arteries when the heart beats and pumps blood).

Review of the Medication Administration Record (MAR) for December 2025, January 2026, and February 1, 2026 through 18, 2026, revealed that Midodrine was administered 15 times outside of the physician ordered parameters, as evidenced by the following documented blood pressure readings at the time of administration: December 10, 2025, 4:00 PM BP 112/68 mm/Hg (millimeters of hemoglobin)December 12, 2025, 11:00 AM BP 122/70 mm/HgDecember 17, 2025, 7:00 AM BP 102/60 mm/HgDecember 18, 2025, 11:00 AM BP 122/94 mm/HgDecember 20, 2025, 11:00 AM BP 102/76 mm/HgDecember 21, 2025, 7:00 AM BP 120/60 mm/HgDecember 26, 2025, 7:00 AM BP110/76 mm/HgJanuary 5, 2026, 11:00 AM BP 115/63 mm/HgJanuary 9, 2026, 11:00 AM BP112/89 mm/HgJanuary 20, 2026, 11:00 AM BP 111/62 mm/HgJanuary 22, 2026, 7:00 AM BP 102/74 mm/HgJanuary 23, 2026, 11:00 AM BP 104/56 mm/HgFebruary 9, 2026, 11:00 AM BP 108/58 mm/HgFebruary 10, 2026,11:00 AM BP109/68 mm/HgFebruary 17, 2026, 7:00 AM BP 118/78 mm/Hg These administrations occurred despite the physician's explicit hold parameters to hold medication for a systolic reading of greater than 100 mm/Hg

During an interview on February 20, 2026, at 9:45 AM, the director of nursing acknowledged that nursing staff did not follow acceptable standards of nursing practice related to medication administration. 28 Pa.

Code 211.5(f)(ii)(ix) Medical records. 28 Pa.

Code 211.9 (a)(1)(d) Pharmacy services. 28 Pa.

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

Code 211.12 (c)(d)(1)(3)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

The facility failed to provide necessary care and services to prevent development and worsening of pressure injuries and failed to follow physician orders, care plans, and professional standards of practice resulting in harm.

Refer F-F692 28 Pa.

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

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

Code 211.12(c)(d)(1)(3)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

addressing the resident's access to scissors or alternative safety measures such as supervised use

services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

During an interview on February 19, 2026, at 2:30 PM the aforementioned

documentation to clinically support the use of the indwelling Foley catheter for Resident 16 related to obstructive uropathy with retention. 28 Pa.

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

Code: 211.12 (c)(d)(3)(5) Nursing Services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

During an interview on

document Resident 15's January 2026 monthly weight as required.

The facility did not provide

order and policy to identify potential nutritional decline in a resident with a progressive neurological condition.

Refer F68628 Pa Code 211.5 (f) Medical records 28 Pa Code 211.10 (a)(c)(d) Resident care policies 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

Observation on February 18, 2026, at 12:30 PM, in the presence of Employee 3, LPN, revealed the PICC dressing was dated February 8, 2026.

The dressing should have been changed on February 15, 2026, in accordance with the seven-day requirement.

Employee 3 acknowledged the dressing was overdue. A second observation on February 19, 2026, at 9:00 AM, revealed the dressing remained dated February 8, 2026, and had not been changed. A review of the February 2026 Treatment Administration Record (TAR) revealed the dressing change scheduled for February 15, 2026, was not signed and left blank. A physician order for Resident 75 dated November 8, 2025, directed staff to administer Cefepime HCL (a broad-spectrum intravenous antibiotic used to treat serious bacterial infections) 100 grams intravenously three times daily until March 5, 2026. A review of Resident 75's February 2026 Medication Administration Record (MAR) revealed the following doses were left blank and not signed as administered: February 7, 2026, at 10:00 PM,February 11, 2026, at 2:00 PM,February 12, 2026, at 2:00 PM,February 13, 2026, at 10:00 PM,February 16, 2026, at 10:00 PM.

Blank entries on the MAR indicate the facility did not document administration of ordered IV antibiotics. A physician order for Resident 75, dated January 30, 2026, directed staff to measure and document the circumference of the upper arm at the PICC insertion site every evening shift.

Measuring arm circumference identifies swelling that may indicate infection or thrombosis. A review of the February 2026 MAR revealed:Arm circumference measured 22 centimeters from February 1, 2026, through February 6, 2026.February 7, 2026, was left blank.Measurements remained 22 centimeters from February 8 through February 15, 2026.February 16, 2026, was left blank.February 17, 2026, measured 22 centimeters.February 18, 2026, measured 25 centimeters.February 19, 2026, was left blank.

Following surveyor inquiry, Employee 3 measured the resident's arm circumference on February 20, 2026, at 10:40 AM, and obtained a measurement of 27 centimeters.

This reflected a 5-centimeter increase from the documented baseline of 22 centimeters.

Employee 3 stated she was unsure why there was a discrepancy in measurements, why the increase was not investigated, and why the physician was not notified.

During interviews on February 19 and February 20, 2026, the Director of Nursing reviewed and confirmed the above findings regarding Resident 3's central venous catheter and Resident 75's PICC line management.

The facility failed to follow its own policies and physician orders related to sterile dressing maintenance, tubing changes, antibiotic administration, monitoring of catheter sites, documentation, and physician notification. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa.

Code 211.12 (c)(d)(1)(3)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

8:47 AM for a pain scale of 7.February 5, 2026, at 1:23 PM for a pain scale of 5.February 6, 2026, at

7:05 PM for a pain scale of 6.February 13, 2026, at 7:59 AM for a pain scale of 4.February 15, 2026, at

7:05 PM for a pain scale of 6.February 19, 2026, at 9:02 AM for a pain scale of 7. An interview with the Director of Nursing on February 20,2026, at 11:10AM reviewed the above findings which demonstrated staff administered the narcotic pain medication outside of the physician ordered pain scale parameter for Resident 64. 28 Pa.

Code 211.10(c)Resident care polices.28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

During an interview on February 19, 2026, at 12:00 PM, the Director of Nursing reviewed the above findings regarding the facility's failure to ensure accurate reconciliation of Resident 64's controlled substances and failure to consistently complete required shift-to-shift narcotic counts. 28 Pa Code 211.5(f)(xi) Medical records. 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.10 (a)(c) Resident care policies. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

Based on observation, review of select facility policy and clinical records, and staff interviews, it was

medications in one of two medication carts observed (Cart A).

Findings include:

Review of the facility policy titled Medication Labeling and Storage last reviewed by the facility February 2, 2026, indicated that if a multi-use medication vial/injectable (container of liquid medication intended for injection of more than one dose) had been opened and accessed (needle was inserted through the rubber stopper and medication was withdrawn) the vial should be dated and discarded within 28 days unless the manufacturer specified a different date for that opened vial. An observation of the medication cart located on Unit 1 Hall Cart A on February 19, 2026, at 8:22 AM, in the presence of Employee 5 (Registered Nurse-RN), of the medication stored in the medication cart, revealed one (1) multi-dose insulin pen of Insulin Aspart (a short acting insulin medication used to lower blood sugar) and two (2) multi-dose pens of Insulin Lispro (a rapid acting insulin medication used to lower blood sugar) that had been opened and available for resident use, but not dated with an opened date or expiration date, despite the sticker on the pen having an area to document the date opened and expiration date.

Further observation revealed one (1) multi-dose insulin pen of Insulin Aspart (a short-acting insulin used to lower blood sugar) with a date on the sticker of the pen documenting the pen was opened and currently in use, with an opened date of January 2, 2026, with no expiration date documented.

Review of manufacturer safety information revealed the multi-dose pen of Insulin Aspart is to be discarded 28 days after opening indicating the dated pen should have been discarded on January 30, 2026.

Interview with Employee 5, Registered Nurse, on February 20, 2026, at 8:24 AM, confirmed that two multi-dose insulin pens of Insulin Lispro and one insulin pen of Insulin Aspart had been opened, were available for use, were actively being used for medication administration, and were not labeled with expiration dates.

Employee 5 further confirmed that the Insulin Aspart pen should have been discarded 28 days after opening; however, it remained in the medication cart and available for use beyond that timeframe.

Interview with the Director of Nursing (DON) on February 20, 2026, at 11:00 AM, reviewed the above findings of the facility's failure to ensure the facility staff adhere to the policy of dating and storing multi-dose pens of insulin. 28 Pa.

Code 211.9(a)(1)(k) Pharmacy services. 28 Pa.

Code 211.10 (c) Resident care policies.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

Based on a review of scheduled facility mealtimes, select facility policy, and resident and staff

residents, including experiences reported by six out of six residents during a group interview (Residents 6, 19, 58, 64, 80, and 101).

Findings include: A review of the facility policy titled Dining Options for Meal Service, last reviewed by the facility on February 2, 2026, revealed it is the facility policy that meals will be served regularly according to the community schedule of dining times, with no more than 14 hours between the time the evening meal is offered and the breakfast meal is offered.

The policy indicates that an HS snack (evening snack) must be offered to all residents. A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds 14 hours.

Specifically, residents eating in the dining room are scheduled to receive dinner at 5:00 PM.Breakfast is served in resident rooms with:Nursing Unit 2 resident rooms 80 to 93 are scheduled to receive breakfast at 7:15 AM.

The scheduled time between dinner and breakfast the next day is 14 hours and 15 minutes.Nursing Unit 1 resident rooms 1 to 36 are scheduled to receive breakfast at 7:30 AM.

The scheduled time between dinner and breakfast the next day is 14 hours and 30 minutes.Nursing Unit 2 resident rooms 60 to 78 are scheduled to receive breakfast at 7:45 AM.

The scheduled time between dinner and breakfast the next day is 14 hours and 45 minutes.Nursing Unit 1 resident rooms 37 to 57 are scheduled to receive breakfast at 8:00 AM.

The scheduled time between dinner and breakfast the next day is 15 hours.

During a resident council interview on February 19, 2026, at 10:00 AM, six out of six residents (Residents 6, 19, 58, 64, 80, and 101) indicated that a snack is not offered between dinner and breakfast the following day. Resident 6 explained that only one nurse offers snacks to residents in the evening, and she is not a regular nurse.

Residents 19, 58, 64, 80, and 101 explained that they are not offered evening snacks.

During an interview on February 20, 2026, at approximately 11:30 AM, the above information was reviewed with the nursing home administrator (NHA).

The NHA was not able to provide documented evidence that snacks were consistently offered to residents in the evening.

The NHA confirmed it is the facility's policy to offer residents nourishing snacks in the evening. 28 Pa.

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

Code 211.12 (d)(3)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707

Review of the facility Credentialing of Nursing Service Personnel Policy last reviewed February 2, 2026, indicated that nursing service personnel who require a license or certification to provide resident care or treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment.

Nursing personnel requiring a license or certification are not permitted to perform direct resident care services until all licensing and background checks have been completed.Observation on February 18, 2026, at 10:30 AM revealed that Employee 2 Licensed Practical Nurse (LPN) was working on the D Hall on Unit

• Interview with the director of nursing (DON) on February 18, 2026, at 1:00 PM revealed that

Employee 2 (LPN) was newly hired and had been sent home.

The DON noted that he was notified by human resources that upon review of her personnel file there was inadequate proof that Employee 2 (LPN) had a valid Pennsylvania LPN license.

Review of Employee 2's (LPN) personnel file revealed that she was hired as an LPN on January 28, 2026.

Employee 2 (LPN) received a Practical Nursing Program Diploma on November 14, 2025. An Exam Appointment History revealed that Employee 2 (LPN) took the Practical Nurses Exam on January 23, 2026, and passed.

However, there was no evidence of a Pennsylvania Practical Nurse license in her personnel file.

Interview with the DON on February 20, 2026, at 9:40 AM revealed that Employee 2's (LPN) Practical Nurse license was issued on February 18, 2026, with an effective date of February 18, 2026, and expiration date of June 30,

• The DON confirmed the delay in the license being issued was due to the need for verification

being provided to the state licensing board for Employee 2's (LPN) required mandatory Child Abuse online training.

Once the verification of the completed mandatory Child Abuse online training was received the employee's license was issued.

Review of Employee 2 (LPN) time punches revealed that prior to February 18, 2026, the employee worked at the facility on the following dates before being issued a license from the Pennsylvania Bureau of Professional and Occupational Affairs: January 28, 2026, February 2, 3, 4, 5, 7, 9,11,12,13,15, 16, and February 17, 2026.

Interview with the Nursing Home Administrator (NHA) on February 20, 2026, at 10:30 AM confirmed that human resources did not complete a license verification upon hire for Employee 2 (LPN) as per facility policy.

The NHA confirmed that Employee 2 (LPN) should not have been able to work at the facility without a verified license. 28 Pa.

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

Code 201.19 (1)(3) Personnel policies and procedures. 28 Pa.

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

Code 211.12 (c)(d)(1)(3)(5) Nursing services.

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Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707