Inspection·April 18, 2025

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview and review of the Resident Assessment Instrument Manual, it was determined the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for six of 22 residents reviewed (Residents 70, 77, 58, 100, 78, and 47). Residents Affected - Many Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (federally-mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that all MDS assessments must be submitted within 14 calendar days of the MDS Completion Date (Z0500B + 14 days). A review of Resident 70's quarterly MDS with an Assessment Reference Date (ARD) of February 20, 2025, revealed that Section Z0500B was not completed or submitted on or before March 8, 2025 (within 14 days of the ARD date) and remained incomplete and not submitted to the QIES ASAP system through survey ending April 18, 2025. A review of Resident 77's quarterly MDS with an ARD of February 17, 2025, revleaed that Section Z0500B was not completed or submitted on or before March 5 (within 14 days of the ARD date) and remained incomplete and not submitted to the QIES ASAP system through survey ending April 18, 2025. Further review of Resident 77's clinical record revealed a quarterly MDS assessment with an ARD of September 25, 2024. Section Z0500B was not completed or submitted on or before October 11, 2024 (within 14 days of the ARD date) and remained incomplete and not submitted to the QIES ASAP system through survey ending April 18, 2025. A review of Resident 58's quarterly MDS with an ARD of February 25, 2025, revealed that Section Z0500B was not completed or submitted on or before March 10, 2025 (within 14 days of the ARD date) and remained incomplete and not submitted to the QIES ASAP system through survey ending April 18, 2025. A review of Resident 100's clinical record revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of February 24, 2025, revealed that Section Z0500B was not completed or submitted on or before March 14, 2025 (within 14 days of the ARD date) and remained incomplete and not submitted to the QIES ASAP system through survey ending April 18, 2025. (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 4 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 04/18/2025 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)