Inspection·March 27, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interview, it was determined the facility failed to assure that one resident (Resident 2) out of 15 sampled were free from physical abuse perpetrated by another resident (Resident 1). Findings include: A review of facility policy titled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation last reviewed by the facility on November 12, 2024, revealed it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). and malignant neoplasm of the prostate (cancerous tumor in the prostate gland). 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 March 14, 2025, indicated the resident was moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status - a tool to assess cognition, a score of 8-12 indicates moderate cognitive impairment), and was independent for ambulation. A review of Resident 1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included dementia with behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression), and parkinsonism (a broad term for various neurodegenerative diseases that cause motor symptoms with symptoms similar to Parkinson's disease). A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 0 (a score of 0-7 indicates severe (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 03/27/2025 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)