Inspection·June 28, 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. Based on review of clinical records and staff interview, it was determined that the facility failed to timely consult with the physician regarding a significant weight gain displayed by one resident out of 20 sampled (Resident 55). Findings include: A review of facility policy titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol last reviewed by the facility June 12, 2024, revealed that the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. A review of facility policy titled Weight Assessment and Intervention last reviewed by the facility June 12. 2024, revealed that any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. A review of the clinical record revealed that Resident 55 was admitted into the facility on January 19, 2024, with diagnoses to include acute systolic congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues) and the presence of a cardiac pacemaker (device implanted in our body to deliver electrical impulses to your heart to help your heartbeat at a normal rate and rhythm). A review of the resident's weight record revealed that the resident weighed 127 pounds on May 29, 2024. On May 30, 2024, it was noted the resident weighed 135.8 pounds. The resident had an 8.8-pound weight gain in one day, which was a 6.48% weight gain. No re-weight was retaken the next day as per policy. Review of a nutrition note dated May 31, 2024, at 10:17 AM the dietitian indicated that the resident's weights were reviewed with weight fluctuations noted. MD made aware of the daily weights on 5/29/24. Notify MD if 5-pound weight gain in 7 days is noted. Will continue to monitor for significant change. However, there was no documented evidence that the physician was notified of the resident's significant weight gain recorded on May 30, 2024. The was no documented evidence that a re-weight was retaken the next day as per policy to confirm the signifcant weight change. Interview with the facility Dietitian on June 26, 2024, at 1:55 PM confirmed that the facility failed to timely notify the physician of the resident's significant weight gain recorded on May 30, 2024. (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 12 Event ID: 395542 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 395542 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mountain Top Rehabilitation & Healthcare Center 185 South Mountain Boulevard Mountain Top, PA 18707 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)