Health inspection·July 11, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record review, review of facility documentation, and resident and staff interview, it was determined that the facility failed to ensure that the resident environment remains free of accident hazards for two of two residents reviewed (Residents 1 and 2). Findings include: Clinical record review for Resident 1 revealed a diagnosis list that indicated the resident is dependent on renal dialysis. Current physician orders for Resident 1 indicated the resident had a chair time for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) at a dialysis center three days a week. The resident utilizes a wheelchair and is transported to and from these appointments by the facility. A quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) for Resident 1 dated June 11, 2024, indicated that staff had assessed the resident as having a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was not cognitively impaired. An interview with Resident 1 on July 11, 2024, at 2:19 PM revealed the resident was being transported in the transport van and stated, I fell out of the wheelchair. When asked if he had a seatbelt on the resident stated, Nope. Review of the job position summary for the Transport Driver position revealed a position responsibility that included, Assist with resident transport within and outside the facility. Operates the lift, helps secures the residents in the van, and assists the Transportation Aide getting the residents into office buildings or hospitals. Facility documentation revealed an interview between Resident 1 and the Nursing Home Administrator (NHA) dated July 3, 2024, with no time stamp noted, that indicated the resident, .noted he fell out of his chair during transport and slid a few feet and top of head hit the chair in front of him. He stated he did not have his seatbelt on. The resident reported some pain in his lower back and some pain in his neck when he turned his head. The interview further asked if the resident thought to ask someone about his seatbelt and he said he knew something was different but did not think to ask. A witness statement with the date of event noted as July 3, 2024, from Employee 1, transport driver, reported the employee was transporting the resident back from dialysis at 11:36 AM, when the aide (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395045 Printed: 05/15/2026 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 395045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mountain View Rehabilitation and Senior Living Ctr 2050 Trevorton Road Coal Township, PA 17866 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)