Inspection·January 3, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, and staff interview it was determined the facility failed to monitor and evaluate weight and hydration requirements of a resident to ensure acceptable parameters of nutritional status are maintained to the extent possible for one resident out of six sampled (Resident A1). Residents Affected - Few Findings include: Review of the facility Resident Weight Policy last reviewed December 2024 indicated weights must be obtained routinely to monitor nutritional health over time. Each resident's weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk is identified, or as ordered. Review of the Resident Hydration Policy last reviewed December 2024 indicated residents will be offered/administered sufficient fluid intake to maintain hydration. A variety of fluids will be offered to residents, depending on preference and nutritional/diagnosis considerations. A dietitian will evaluate resident fluid status within 14 days of admission, quarterly, and as needed. This may include laboratory testing by the provider as ordered. Fluids include water, juices, coffee/tea, gelatin, ice cream, soups, popsicles, and any other substance which is essentially liquid in nature. Nursing staff will be primarily responsible for resident fluid intake during and between meals. Fluids may be provided by others determined by resident fluid and dietary orders (such as activities, dietary, visitors). Nursing, medical providers, and dietitians will monitor for signs of dehydration and monitor resident medications which may alter fluid balance. Fluids will be provided with meals, snacks, and at the bedside, unless otherwise ordered by the provider. If resident fluid status is identified as inadequate, the interdisciplinary team will discuss with the resident and provider and determine if alternative (non-oral) methods of hydration are desired/warranted. A review of the clinical record revealed Resident A1 was admitted to the facility on [DATE], with diagnoses which included dementia, congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), and chronic kidney disease (disease characterized by progressive damage and loss of function to the kidneys). A review of the resident's quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 3, 2024, indicated the resident was severely cognitively impaired with a BIMS (brief screener that aids in detecting cognitive impairment) score of 0 (a score of 0-7 indicates severe cognitive impairment). A physician order dated October 19, 2024, noted an order for Furosemide (a diuretic or water pill, (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: 395582 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 01/03/2025 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)