Inspection·February 2, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to notify the resident's physician of an incident for two of 23 sampled residents. (Residents 75, 109) Findings include: Review of the facility policy entitled, Resident Change in Condition, last reviewed March 16, 2023, revealed that the physician would be notified as soon as the nurse identified a change in condition, accident, or incident. The nurse would record the notification in the resident's health record. Clinical record review revealed that Resident 75 was admitted to the facility on [DATE], with diagnoses that included muscle weakness, senile degeneration of the brain, and repeated falls. Review of a nurse's noted dated November 30, 2023, revealed that Resident 75 had a fall. There was no documented evidence that the resident's physician was notified of the fall. In an interview on February 2, 2024, at 9:42 a.m., the Regional Nurse confirmed that there was no documented evidence that the resident's physician was notified of the fall. Clinical record review revealed that Resident 109 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction (weakness or paralysis after a stroke), low back pain, anxiety, and depression. Review of a nurse's noted dated January 31, 2024, revealed that Resident 109 was found in possession of unmarked pills, empty medication bottles, medication bottles containing pills, and empty medication cards. There was no documented evidence that the resident's physician was notified of the incident per facility policy. In an interview on February 2, 2024, at 9:30 a.m., the Regional Nurse confirmed that there was no documented evidence that the resident's physician was notified at the time of the incident. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 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 6 Event ID: 395494 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 395494 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Slate Belt Health & Rehabilitation Center 701 Slate Belt Blvd, Rd 3 Bangor, PA 18013 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)