Inspection·March 20, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 14 residents residing on the 200-unit, three out of four residing on the 300 unit, and two out of eight residing on the 400 unit, expressed similar complaints regarding untimely staff response to their requests for care and assistance. Interview with Resident 141 on March 20, 2024, at approximately 9:47 AM, revealed that she has waited over an hour at times for staff to answer her call bell. More recently on March 17, 2024, she stated that she was soaked with urine after being incontinent and then 2nd shift (3:00 PM - 11:00 PM) got mad that they had to change her and all her bed linens because of the urine. Interview with Resident 6 on March 20, 2024, at approximately 10:02 AM, revealed that he feels that short staffing is a problem in the facility because he waits 20 -30 minutes, 2 or 3 times a week, for staff to answer his call bell. The resident stated that these waits occur mostly on 1st (day shift) of nursing duty, during lunch time. Interview with Resident 17 on March 20, 2024, at approximately 10:09 AM, revealed she waits long time, greater than 30 minutes, for staff to answer her call bell, and that there have been times she has soiled herself while waiting for the call bell to be answered. Resident 17 indicated the extended wait time is daily, and occurs at any time (day, evening, or night shift). Interview with Resident 163 on March 20, 2024, at approximately 10:15 AM, revealed she has waited over for staff to answer her call bell waiting for as needed medication. Resident 163 states I become very frustrated when it gets to an hour, because I am in pain. I know the staff are busy with other patients, but I am a patient too. Interview with Resident 24 on March 20, 2024, at approximately 10:17 AM, revealed that she feels the building needs more help, because she has waited greater than 1 hour for assistance. The resident stated that these waits occur weekly, mostly on 1st (day shift) of nursing duty. Interview with Resident 112 on March 20, 2024, at approximately 10:40 AM, revealed that he has waited as recent as last week for 30 minutes to get some water. Interview with Resident 113 on March 20, 2024, at approximately 10:42 AM, revealed that he waits up to an hour for someone to answer his call bell. The resident states I would do things myself, but I need staff to help me, that is why I am here. Interview with Resident 117 on March 20, 2024, at approximately 10:46 AM, revealed that she waits a minimum of 30 minutes on 2nd shift and 3rd shift (11:00 PM - 7:00 AM) on a regular basis. About a month ago she waited over an hour for staff to assist her. This resident requires extensive assistance with transfers, repositioning, toileting, and activities of daily living (ADLs). Interview with Resident 27 on March 20, 2024, at approximately 1:15 PM, revealed that he waits 30 - 45 minutes, weekly, for staff to answer his call bell. The resident stated that these waits occur mostly on 2nd (evening shift) of nursing duty. Interview with Resident 43 on March 20, 2024, at approximately 10:38 AM, revealed that she feels that short staffing is a problem in the facility because they are slow to answer the call bell. Resident 43 stated she waits up to 1 hour, daily, for staff to answer her call bell. The resident stated that these waits occur mostly on 1st (day shift) of nursing duty, and that there have been times she has soiled herself while waiting for the call bell to be answered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395582 If continuation sheet Page 2 of 4 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 395582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mountain City Nursing & Rehabilitation Center 403 Hazle Township Boulevard Hazleton, PA 18202 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Resident 53 on March 20, 2024, at approximately 11:06 AM, revealed that she waits 30 - 40 minutes, once in a while, for staff to answer her call bell. The resident stated that these waits occur mostly on 3rd (night shift) of nursing duty. Interview with Resident 54 on March 20, 2024, at approximately 11:11 AM, revealed that she can wait greater than 1 hour, daily, for staff to answer her call bell. The resident stated that these waits occur mostly on 3rd (night shift) of nursing duty. Interview with Resident 58 on March 20, 2024, at approximately 11:24 AM, stated you can wait till your dead, hours, for staff to answer the call bell. According to Resident 58, this occurs 1 or 2 times a week. The resident stated that these waits occur mostly on 1st (day shift) of nursing duty, morning, after breakfast. Interview with Resident 72 on March 20, 2024, at approximately 10:55 AM, revealed that he waits greater than 30 minutes, 2 or 3 times a week, for staff to answer his call bell. The resident stated that these waits occur mostly on 1st (day shift) of nursing duty, during lunch time. Interview with Resident 77 on March 20, 2024, at approximately 10:49 AM, revealed that she waits 30 - 45 minutes, twice weekly, for staff to answer her call bell. The resident stated that these waits occur mostly on 2nd (evening shift) of nursing duty. Interview on March 20, 2024, at approximately 3:15 PM with the Nursing Home Administrator (NHA) verified that it is her expectation that all residents be treated with dignity and respect. The NHA was unable to explain why multiple residents are reporting untimely staff response times to their requests for care and assistance, resulting in the residents' feelings that the facility is not adequately staffed, which was negatively affecting the residents' quality of life in the facility. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa Code 211.12 (d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395582 If continuation sheet Page 3 of 4 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 395582 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mountain City Nursing & Rehabilitation Center 403 Hazle Township Boulevard Hazleton, PA 18202 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in resident areas on four of five nursing units (Blue Building Unit 200, 300, [NAME] Building Unit 100 and 200). Findings included: An observation of resident lounge area on the third floor of the Blue Building on March 20, 2024, at 12:51 PM, revealed a dried brown fecal-like substance on the seat cushion of a teal-colored dining chair, that had a foul odor. An observation of resident dining area on the second floor of the Blue Building on March 20, 2024, at 12:55 PM, revealed a large soiled area from an unknown substance on the seat cushion of a teal-colored dining chair. An observation of resident sitting area on the second floor of the Blue Building on March 20, 2024, at 12:56 PM, revealed multiple brown and white stained areas of from an unknown substance on the seat cushion of a teal-colored chair. An observation of resident sitting area on the second floor of the [NAME] Building on March 20, 2024, at 1:07 PM, revealed a worn armrest of a cushioned sofa chair. An observation of resident dining area on the second floor of the [NAME] Building on March 20, 2024, at 1:09 PM, revealed multiple brown stains from an unknown substance on the seat cushions of two beige colored dining chairs. An observation of resident dining area on the first floor of the [NAME] Building on March 20, 2024, at 1:11 PM, revealed multiple brown and white stained areas of from an unknown substance on the seat cushion of a teal-colored dining chair. An observation of resident sitting area on the first floor of the [NAME] Building on March 20, 2024, at 1:13 PM, revealed a cushioned fabric recliner to have multiple stained areas on the seat and the fabric was worn. A sofa couch was observed to be worn and torn on the left and right side of the armrests exposing the underlying cushion of the couch. An interview with the DON on March 19, 2024 at approximately 1:20 PM in the third floor resident lounge in the Blue Building confirmed the brown fecal-like substance on the seat cushion of a chair and stated she would inform maintenance staff to have it cleaned immediately. During an interview on March 19, 2024, at approximately 2:45 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility's environment should be kept in good repair and maintained in a clean and homelike manner. 28 Pa Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395582 If continuation sheet Page 4 of 4