Inspection·May 28, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ambulate 250 feet with a rolling walker and contact guard/minimal assistance wearing the heel off-loading shoe on his right foot approximately a week ago, but now reporting that he was told by his doctor that he needs to stay in bed for a week and not walk on his foot, but nursing staff reported no orders were received by the physician. Physical therapy documentation for Resident 1 dated May 16, 2025, noted a precaution as weight bearing as tolerated right lower extremity. The documentation revealed that the resident ambulated with a rolling walker and minimal assistance of one and chair follow. He utilized the heel off-loading shoe and tolerated distances up to 110 feet. Physical therapy documentation for Resident 1 dated May 21, 2025, noted a precaution as weight bearing as tolerated right lower extremity. Documentation further noted the resident ambulated with a rolling walker and minimal assistance of one with chair follow and tolerated distances up to 40 feet. The resident utilized a right heel off-loading shoe. Physical therapy documentation for Resident 1 dated May 22, 2025, noted a precaution as weight bearing as tolerated right lower extremity. The documentation revealed the resident had ambulation distances of 40-250 feet using a rolling walker and contact guard/minimal assistance. A complexity included that the resident continued reports of right heel pain. An interview with Employee 1, Director of Rehabilitation, on May 28, 2025, at 1:07 PM revealed that Resident 1 is non-weight bearing on the right foot per the wound care consultation appointments and the correspondence was just received today. Employee 1 further noted the resident was refusing the weight bearing exercises (such as ambulation) because he could not tolerate it, and the facility was using a wedge shoe to relieve pressure on the heel. Further clinical record review for Resident 1 revealed the following orders dated May 28, 2025: Utilize a wheelchair for stand pivot transfers to the toilet; PRAFO boot to be worn on the right lower extremity and regular shoe on the left foot for transfers and no ambulation at this time; and assist of one with rolling walker wearing PRAFO on right lower extremity for transfers only and no ambulation at this time. A review of Resident 1's task list (located in the electronic health record where staff document specific care related events for a resident) revealed the following tasks entered May 28, 2025: use wheelchair for stand/pivot transfers to toilet; no ambulation in room due to restrictions per the physician; assist of one with a rolling walker wearing PRAFO on right foot and regular shoe on the left foot; and special instructions/restrictions of no ambulation permitted at this time due to right heel pressure ulcer. Further review of Resident 1's care plan, tasks, and physician orders revealed no evidence that the recommendations made by the medical provider at the wound care consultation appointments were transcribed to the resident's medical record after the resident's appointments on May 5 and 23, 2025. Or that physical therapy staff were made aware of the recommendations until May 28, 2025, as per the interview with Employee 1. An interview with the Director of Nursing on May 28, 2025, at 2:45 PM revealed that there were no additional orders or tasks located in Resident 1's chart to indicate the recommendations from the wound care consultation appointments were transcribed from the consultation report to the electronic medical record, which should have been completed by nursing staff upon the resident returning from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395045 If continuation sheet Page 2 of 3 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 05/28/2025 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)

F 0842 appointments. Level of Harm - Minimal harm or potential for actual harm The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on May 28, 2025, at 3:45 PM. Residents Affected - Few 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395045 If continuation sheet Page 3 of 3