Health inspection·October 5, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, a review of clinical records, select facility policy, current infection control guidance and the facility's resident testing logs for COVID-19 infection, and staff interview, it was determined that the facility failed to implement and maintain infection control practices, including infection control precautions, to prevent spread of infection COVID-19. Residents Affected - Some Findings include: According to information provided by the Centers for Disease Control and Prevention (CDC) dated September 23, 2022, and updated February 8, 2023, health care providers that test positive for COVID-19 and are asymptomatic throughout their infection and not moderately to severely immunocompromised could return to work after the following criteria have been met: at least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). Interview with the Nursing Home Administrator on October 5, 2023, at approximately 9 AM revealed that on September 30, 2023, Employee 1, registered nurse, tested positive for COVID-19 at the beginning of her shift during routine outbreak testing. According to the NHA, Employee 1 was not symptomatic at the time of testing and despite testing positive for COVID-19 was permitted to remain in the facility and complete her scheduled 16-hour shift (3 PM to 7 AM). The NHA further stated that Employee 1 wore an N-95 mask, a face shield, and remained in the COVID area during her 16-hour shift. However, a review of the facility's current floor plan revealed that the facility did not have a designated COVID-19 isolation area for the residents that had tested positive for COVID-19 despite having vacant rooms and open beds available in the facility during the outbreak. The NHA confirmed that Employee 1 was permitted to remain in the facility working and not limited to a designated COVID unit as the facility did not have a designated COVID area where all COVID positive residents were housed and cohorted. According to information provided by the Pennsylvania Department of Health 2023-PAHAN-694 dated May 11, 2023, placement of residents with suspected or confirmed SARS-CoV-2 infection: ideally, residents should be placed in a single-person room. If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. However, quarantined patients and those with suspected infection should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. (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 2 Event ID: 395357 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 395357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ellen Memorial Rehabilitation and Healthcare Cente 23 Ellen Memorial Lane Honesdale, PA 18431 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)