Health inspection·December 11, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect for one of four residents reviewed (Resident 2) who was transferred incorrectly, resulting in a fall with a head laceration requiring staples. This deficiency was cited as past noncompliance. Findings include: The facility's abuse policy, dated September 11, 2024, indicated that the facility will not tolerate abuse, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The facility's policy on mechanical lifts, dated September 11, 2024, indicated that a two-person assist is required for all mechanical lifts, including Hoyer lifts (a mechanical lift that features a U-shaped base, an overhead bar, and a sling that work together to lift, reposition, and lower a patient into a chair or bed). A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated November 6, 2024, indicated that the resident understood and was understood by others, was cognitively intact, was dependent on staff for daily care needs, and had diagnoses that included quadriplegia (a medical condition where the person has all loss of movement in all arms and legs), and multiple sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord). A nursing note for Resident 2, dated November 28, 2024, at 8:17 p.m., indicated that the resident was being transferred onto his bed by Nurse Aide 1 by a mechanical lift when the sling pad slipped from under the resident and he hit his head on the headboard resulting in a laceration to the back of his head. The physician was notified and new orders were received to transfer the resident to the emergency room. A nursing note for Resident 2, dated November 28, 2024, at 9:15 p.m., revealed that the resident returned from the emergency room with three staples to the back of his head. An incident report for Resident 2, dated December 6, at 12:05 p.m., revealed that the resident was transferred in a Hoyer lift by Nurse Aide 1. The sling pad slipped from under the resident causing him to hit his head on the headboard resulting in a laceration that required three staples. Page 1 of 4 395726 395726 12/11/2024 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0600 Nurse Aide 1 received the facility's abuse training on June 4, 2024. Level of Harm - Actual harm Interview with the Director of Nursing on December 11, 2024, at 10:08 a.m. confirmed that Nurse Aide 1 was aware of the facility's policy for transferring a resident with two persons in a Hoyer lift and should have had a second person assist with the transfer of Resident 2. Residents Affected - Few A review of the facility's plan of correction included the following: Reeducation on transporting residents in mechanical lifts and transfers completed for all nursing staff, including nurse aides, licensed practical nurses, and registered nurses. Audits of residents that require mechanical lifts and assist with transfers. Audits to be completed three days a week for four weeks to ensure proper transfer status is being used. Interviews with nursing staff on December 11, 2024, revealed that they had been educated on proper transfers of residents. A review of the facility's corrective actions revealed that they were in compliance with F600 on December 3, 2024. Interview with the Director of Nursing on December 11, 2024, revealed that staff education was completed and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395726 Page 2 of 4 395726 12/11/2024 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on review of facility policies, investigation documents, and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of four residents reviewed (Resident 2), resulting in an incident that required staples for a laceration on his head. This deficiency was cited as past non-compliance. Findings include: The facility's policy on mechanical lifts, dated September 11, 2024, indicated that a two-person assist is required for all mechanical lifts, including Hoyer lifts (a mechanical lift that features a U-shaped base, an overhead bar, and a sling that work together to lift, reposition, and lower a patient into a chair or bed). A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated November 6, 2024, indicated that the resident understood and was understood by others, was cognitively intact, was dependent on staff for care, including transfers and bed mobility, and had diagnoses that included quadriplegia (a medical condition where the person has all loss of movement in all arms and legs), and multiple sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord). The current care plan for Resident 2 indicated that he was a two-person assist for transfers. An incident report for Resident 2, dated December 6, at 12:05 pm., revealed that the resident was transferred in a Hoyer lift by Nurse Aide 1, the sling pad slipped from under the resident, and he hit his head on the headboard causing a laceration that required three staples. Interview with the Director of Nursing on December 11, 2024, at 10:08 a.m. confirmed that two people should have been transferring Resident 2 while using the mechanical lift. A review of the facility's plan of correction included the following: Reeducation on transferring residents in mechanical lifts completed for all nursing staff, including nurse aides, licensed practical nurses, and registered nurses. Audits of residents that require mechanical lifts and assist with transfers. Audits of transfers will be completed three days a week for four weeks to ensure proper transfer status is being used. Interviews with nursing staff on December 11, 2024, revealed that they had been educated on proper transfers of residents. A review of the facility's corrective actions revealed that they were in compliance with F689 on December 3, 2024. Interview with the Director of Nursing on December 11, 2024, revealed that staff education was completed and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting. 395726 Page 3 of 4 395726 12/11/2024 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0689 28 Pa. Code 201.14(a) Responsibility of Licensee. Level of Harm - Actual harm 28 Pa. Code 201.18(e)(1) Management. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395726 Page 4 of 4