Health inspection·June 5, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for six of 39 residents reviewed (Residents 18, 30, 61, 66, 77, 79). Residents Affected - Few Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415F1 (antibiotic medication) was to be checked if the resident received an antibiotic medication during the seven-day look-back period. Physician's orders for Resident 18, dated April 24, 2025, included an order for the resident to receive 1 gram of Cefipime (antibiotic) intravenously every eight hours for seven days for a urinary tract infection. The resident's Medication Administration Record (MAR's) for April 2025 revealed that the resident received Cefipime every eight hours from April 24 through April 29, 2025; however, a significant change MDS assessment for Resident 18, dated May 3, 2025, revealed that Section N0410F1 was not checked, indicating that the resident did not receive any antibiotic medications during the seven-day look-back period. Interview with the RNAC on June 5, 2025, at 10:33 confirmed that Section N0410F1 of Resident 18's significant change assessment of May 3, 2025, was not coded correctly. The RAI User's Manual, dated October 2024, indicated that Section O0110K1 Hospice care (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families) was to be coded to indicate if the resident was receiving hospice services (a) on admission, (b) while a resident or (c) at discharge. Review of Resident 30's clinical record, including physician's orders, care plans and nurses' notes, revealed no documented evidence that the resident was receiving hospice services during the seven-day look-back period; however, a quarterly MDS assessment for Resident 30, dated May 29, 2025, revealed that Section 0O110K1 was coded (b) while a resident, indicating that the resident was receiving hospice services during the seven-day look back-period. Interview with the Registered Nurse Assesment Coordinator on June 5, 2025, at 9:13 a.m. confirmed that Resident 30's MDS, dated [DATE], was coded inaccurately. The RAI User's Manual, dated October 2024, revealed that if the resident had an unhealed pressure ulcer (skin impairment caused by pressure), then Section M0210 was to be coded (1) yes, and the Page 1 of 14 395726 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few number of pressure ulcers was to be coded in Section M0300A for Stage I pressure ulcers (reddened area that does not blanche), Section M0300B for Stage II pressure ulcers (superficial open area or blister), Section M0300C for Stage III pressure ulcers (full thickness skin loss), Section M0300D for Stage IV pressure ulcers (full thickness tissue loss exposing bone, tendons or muscle), Section M0300E for unstageable pressure ulcers related to a non-removable device, Section M0300F for unstageable pressure ulcers due to slough (yellow, tan, or green tissue, usually moist) or eschar (dead tissue this is black or brown in color and may appear scab like), and M0300G for unstageable pressure ulcers related to suspected deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue). A nursing note, dated May 23, 2025, at 5:08 p.m., revealed that Resident 61 was admitted to the facility and the dressing to the bottom of her left heel was removed for drainage. She had a Stage III open area that measured 4 x 3 x 0.5 centimeters (cm). The area was cleansed with normal saline solution (sterile salt water) and Hydrofera blue (antibacterial wound dressing) was applied to the area and covered with a dressing as ordered; however, an admission MDS assessment for Resident 61, dated May 25, 2025 revealed that Section M0210 was coded no (0), indicating that the resident did not have an unhealed pressure ulcer; therefore, Section M0300C (Stage III) was not coded to indicate that the resident had a Stage III pressure ulcer. Interview with the RNAC on June 5, 2025, at 10:33 a.m. revealed that she did not think the resident received a treatment to the left heel and that the area was coded as a diabetic ulcer after the assessment period, so it was not coded as a pressure ulcer. The RAI user's manual, dated October 2024, revealed that Section N0415A Antipsychotic (medication used for behaviors) was to be coded if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 66, dated May 13, 2025, included an order for the resident to receive 150 milligrams of Clozapine (an antipsychotic medication) every day at bedtime. The resident's MAR for May 2025 revealed that the resident received Clozapine daily during the assessment's seven-day look-back period; however, a quarterly MDS assessment for Resident 66, dated May 7, 2025, revealed that Section N0401A was not coded, indicating that the resident did not receive an antipsychotic medication during the seven-day look-back period. Interview with the RNAC on June 4, 2025, at 3:26 p.m. confirmed that Section N0401A of Resident 66's quarterly assessment of May 7, 2025, was not coded correctly. The RAI User's Manual, dated October 2024, indicated that the intent of Section N was to record the number of days during the seven days of the assessment period that any type of injection, insulin, and/or select medications were received by the resident. An admission MDS assessment for Resident 77, dated May 21, 2025, revealed that Section N0300 indicated that the resident did not receive an injection during the seven days of the assessment period; however, a review of Resident 77's Medication Administration Record (MAR) for May 2025 revealed that the resident received a PPD (purified protein derivative - skin test for Tuberculosis administered with a needle) on May 15, 2025. Interview with the RNAC on June 5, 2025, at 10:33 a.m. revealed that she does not code PPD injections. The RAI User's Manual, dated October 2024, indicated that Section N0415I1 (Antiplatelet Medications medications used to reduce the risk of blood clots) was to be checked if the resident received an anti-platelet medication during the seven-day assessment period. A care plan for Resident 79, dated 395726 Page 2 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few March 11, 2025, indicated that the resident was prescribed an antiplatelet. Physician's orders for Resident 79, dated November 7, 2023, included an order for the resident to receive 81 milligrams (mg) of aspirin daily. Review of the resident's Medication Administration Record (MAR) for April and May 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 79, dated May 7, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days. Interview with the RNAC on June 4, 2025, at 1:20 p.m. confirmed that Resident 79's MDS assessment was not coded accurately. 28 Pa. Code 211.5(f) Clinical Records. 395726 Page 3 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect the resident's specific care needs for three of 39 residents reviewed (Residents 30, 77, 91). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 30, dated May 29, 2025, indicated that the resident was cognitively impaired, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine), and had diagnoses that included obstructive uropathy (condition where the flow of urine is blocked within the urinary tract). A care plan for Resident 30, dated January 28, 2025, indicated that the resident had urinary incontinence (the involuntary leakage of urine) and staff were to assess her pattern of urination and episodes of incontinence. A care plan, dated May 12, 2025, indicated that the resident required an indwelling urinary catheter, and that staff were to provide catheter care as ordered. A nurse's note for Resident 30, dated May 10, 2025, indicated that the resident had an indwelling catheter placed. An interview with the Licensed Practical Nurse Assessment Coordinator on June 5, 2025, at 12:15 p.m. revealed that Resident 30's care plan was not revised to remove interventions for urinary incontinence when the resident had an indwelling catheter placed and it should have been. An admission MDS assessment for Resident 77, dated May 21, 2025, indicated that the resident was cognitively impaired, received no anti-psychotic medications, and had diagnoses that included anxiety. Physician's orders for Resident 77, dated May 27, 2025, included an order for the resident's Olanzapine (anti-psychotic medication) to be discontinued. A review of the resident's Medication Administration Record (MAR) for June 2024 revealed that Resident 77 was not receiving an anti-psychotic medication; however, the resident's current care plan indicated that the resident received an antipsychotic medication for anxiety. An interview with the Director of Nursing on June 5, 2025, at 11:38 p.m. confirmed that Resident 77's care plan was not revised to indicate that the resident's anti-psychotic medication was discontinued. A quarterly MDS assessment for Resident 91, dated March 19, 2025, indicated that the resident had moderate cognitive impairment, was independent with personal care needs, and had diagnoses that included dementia. A care plan for Resident 91, dated June 24, 2024, indicated that the resident was receiving antipsychotic medication for depression; however, a review of the Medication Administration Record (MAR) for Resident 91, dated May and June 2025, revealed no documented evidence that the resident was receiving antipsychotic medication. An interview with the Licensed Practical Nurse Assessment Coordinator on June 5, 2025, at 12:13 p.m. confirmed that Resident 91's care plan was not revised to indicate that the resident was not receiving antipsychotic medication and should have been. 395726 Page 4 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0657 28 Pa. Code 201.24(e)(4) admission Policy. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(5) Nursing Services. Residents Affected - Few 395726 Page 5 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's order for treatments for one of 39 residents reviewed (Resident 30). Residents Affected - Few Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 30, dated May 29, 2025, indicated that the resident was cognitively impaired, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine), had diagnoses that included obstructive uropathy (condition where the flow of urine was blocked within the urinary tract), and had a pressure ulcer. A wound consult note for Resident 30, dated February 27, 2025, and March 6, 2025, indicated that the resident was to have her wound cleansed with wound cleanser, gently scrubbing to remove all old ointment and any loose tissue, patted dry, have Medi honey (medical-grade honey used to treat wounds) applied to the wound bed, and covered with a dry border gauze dressing (wound dressing that combines an absorbent gauze pad with a wider, adhesive border for secure placement) daily and as needed for soiling or dislodgement. A wound consult note for Resident 30, dated March 13, 2025, indicated that the resident's prior wound regimen was to be discontinued and that her wound was to be cleansed with 0.125 percent Dakin's Solution (used topically to clean and disinfect wounds and to prevent infection), the wound packed with Dakin's moistened kerlix (type of bandage roll used for wound care) to fill the void and depth, and covered with a dry ABD pad (a type of medical dressing used to absorb fluids and provide padding for wounds) twice a day and as need for soiling or dislodgement. Review of the Treatment Administration Record (TAR) for Resident 30, dated February and March 2025, indicated that from February 28 through March 20 the resident had treatments completed that included having her sacrum cleansed with wound cleanser, patted dry, Medi-honey applied, and covered with calcium alginate (highly absorbent wound dressings made from natural seaweed fibers and calcium salts) and a large border dressing daily. Interview with the Infection Control Nurse on June 5, 2025, at 3:39 p.m., in the presence of the Director of Nursing and Nursing Home Administrator, revealed that she does treatments with the wound consultant every week and receives verbal orders for treatment changes during that time. She was responsible for reviewing the wound consultant's notes each week and to identify any discrepancies between the verbal orders he provides her and the recommendations he includes in his notes. She is responsible to clarify any discrepancies. The infection control nurse confirmed that there were discrepancies that she failed to identify and clarify between the treatment orders that were being completed from February 28 through March 20, 2025, and the wound consultant's recommendations. 395726 Page 6 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0658 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395726 Page 7 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of 39 residents reviewed (Resident 91). This deficiency was cited as past non-compliance. Residents Affected - Few Findings include: The facility policy for medication administration, dated August 14, 2024, indicated that medications are prescribed as ordered by the physician and will be administered by certified healthcare professionals in a behavior consistent with appropriate infection control and standards of practice. A quarterly MDS assessment for Resident 91, dated March 19, 2025, indicated that the resident had moderate cognitive impairment was independent with personal care needs, and had diagnosis that included dementia. Physician's orders for Resident 91 dated June 20, 2024, included for the resident to receive 25 milligrams (mg) of metoprolol tartrate (used to treat high blood pressure) twice a day and to hold the medication if the resident's systolic blood pressure (SBP-top number on a blood pressure reading) was less than 120 millimeters of mercury (mm/Hg). Review of the Medication Administration Record (MAR) for Resident 91, dated January through April 2025, indicated that 25 mg of metoprolol tartrate was administered to the resident on January 14 during the a.m. med pass when the resident's SBP was 110 mm/Hg; February 8 during the p.m. med pass when the resident's SBP was 110 mm/Hg; March 1 during the a.m. med pass when the resident's SBP was 116 mm/Hg; March 6 during the a.m. med pass when the resident's SBP was 118 mm/Hg; April 10 during the p.m. med pass when the resident's SBP was 112 mm/Hg; April 15 during the p.m. med pass when the resident's SBP was 112 mm/Hg; April 17 during the p.m. med pass when the resident's SBP was 112 mm/Hg; April 20 during the p.m. med pass when the resident's SBP was 118 mm/Hg; and April 27 during the p.m. med pass when the resident's SBP was 118 mm/Hg. Interview with the Nursing Home Administrator and Director of Nursing on June 4, 2025, at 4:40 p.m. confirmed that Resident 91 was administered metoprolol tartrate when it should have been held per physician's orders for a SBP less than 120. Following identification that medications were being administered outside of physician ordered parameters, the facility's corrective actions included: Residents who had physician-ordered parameters for medication administration were identified. Education was provided to licensed staff regarding administering medications with parameters and the six rights of medication administration. Audits were completed three times a week for four weeks to identify any medications that were administered outside of physician-ordered parameters and will continue twice monthly for two months. The findings will be reviewed with the quality assurance performance improvement committee. A review of the facility's corrective actions revealed that they were in compliance with F684 on 395726 Page 8 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0684 May 30, 2025. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(1)(5) Nursing Services. Residents Affected - Few 395726 Page 9 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for flushing intravenous (IV) catheters, and/or that intravenous catheters were flushed according to the facility's policy for two of 39 residents reviewed (Residents 54, 61) who had long-term intravenous catheters. Residents Affected - Some Findings include: The facility's policy regarding flushing intravenous catheters (a thin tube placed in a vein that can be used for an extended period of time to deliver fluids and/or medications), dated August 14, 2024, revealed that specific flush orders must be obtained, documented and submitted to the pharmacy. Flushing is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. All peripheral vascular access devices are flushed between incompatible medications with normal saline or other flush solution as recommended by the manufacturer. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated May 19, 2025, revealed that the resident was cognitively intact and was dependent for daily care needs. Physician's orders for Resident 54, dated May 16, 2025, included orders to insert an IV catheter (a thin, flexible tube that is placed in a vein to administer fluids) and start Normal Saline at 80 milliliters (ml)/hour (hr). A nursing note, dated May 16, 2025, at 10:00 a.m., revealed that the nursing supervisor was called to Resident 54's room due to a change in condition. Resident 54 was lethargic, was not responsive, and vital signs were within normal limits. The Certified Registered Nurse Practioner (CRNP - a registered nurse with advanced training to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, prescribe medications and formulate treatment plans) was at the bedside and ordered an IV catheter to be inserted with Normal Saline infusing at 80 ml/hr. The IV catheter was inserted without difficulty with excellent blood return and it flushed well. Review of Resident 54's Medication Administration Records (MAR's) for May 2025 revealed no documented evidence that the IV catheter was inserted, the resident received Normal Saline at 80 ml/hr, or that the IV was flushed. Interview with the Director of Nursing on June 4, 2025, at 1:57 p.m. confirmed that there was no documented evidence that Resident 54 had an IV inserted with Normal Saline infusing at 80 ml/hr or that the IV was flushed. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated May 25, 2025, revealed that the resident was cognitively intact, had IV access, and received an antibiotic. Physician's orders for Resident 61, dated May 23, 2025, included orders for staff to flush the resident's midline using 10 ml of 0.9 percent sodium chloride before and after medication administration, followed by 30 units of Heparin three times a day (6:00 a.m., 2:00 p.m., 9:00 p.m.). Physician's orders for Resident 61, dated May 29, 2025, included orders for the resident to receive 395726 Page 10 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0694 Level of Harm - Minimal harm or potential for actual harm 720 milligrams (mg) of Daptomycin (an antibiotic) intravenously (IV) once a day (5:00 a.m.) and 1 gram of Cefepime (an antibiotic) intravenously every 12 hours (8:00 a.m., 8:00 p.m.). A nursing note, dated May 30, 2025, at 12:28 a.m. revealed the resident was receiving Cefepime and Daptomycin for osteomyelitis (bone infection) of the left heel. Residents Affected - Some Resident 61's Medication Administration Records (MAR's) for May and June 2025 revealed that the resident received IV Cefepime at 8:00 a.m. May 29 through June 4, 2025; however, there was no documented evidence that staff flushed the resident's midline catheter before and after the administration. Interview with the Director of Nursing on June 5, 2025, at 11:45 a.m. confirmed that there was no documented evidence that Resident 61's midline was flushed before and after the administration of Cefepime at 8:00 a.m. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 395726 Page 11 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending June 27, 2024, and April 22, 2025, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending June 5, 2025, identified repeated deficiencies regarding accuracy of Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs), issues with intravenous therapy, and following infection control practices. The facility's plan of correction for a deficiency regarding a failure to ensure that MDS assessments were accurate upon submission, cited during the survey ending June 27, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments. The facility's plan of correction for a deficiency regarding a failure to ensure that intravenous therapy was completed correctly, cited during the survey ending on June 27, 2024, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F694, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding intravenous therapy. The facility's plans of correction for deficiencies regarding infection control practices, cited during the surveys ending June 27, 2024, and April 22, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control practices. Refer to F641, F694, F880. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 395726 Page 12 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 39 residents reviewed (Resident 76). Residents Affected - Few Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding EBP, dated August 14, 2024, indicated that EBP is intended to prevent transmission of MDRO's via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. High-risk residents are those with chronic wounds and indwelling devices (such as central lines, urinary catheters, and tracheostomies (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) and for all those colonized or infected with a MDRO currently targeted by the CDC. High contact activities that may result in transfer of MDRO's to hands and clothing of healthcare personnel, even when blood and body fluid exposure is not anticipated. These include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use, and wound care. Residents placed on EBP should remain on EBP for the duration of their stay or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 76, dated March 26, 2025, revealed that the resident was understood, could understand others, had a diagnosis which included End-Stage Renal Disease (ESRD - permanent kidney failure that requires a regular course of dialysis or a kidney transplant), and received dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to). A care plan for the resident, dated March 7, 2024, revealed that the resident required dialysis and had a right subclavian (located below your collarbone) dialysis catheter (a medical device used for kidney dialysis, providing access to the bloodstream for the process of cleaning waste and excess fluid from the blood). Review of Resident 76's clinical record revealed no documented evidence to indicate that the resident was on EBP's due to having the right subclavian dialysis catheter. Interview with the Infection Control Preventionist on July 31, 2024, at 10:30 a.m. confirmed that 395726 Page 13 of 14 395726 06/05/2025 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was no documented evidence to indicate that Resident 76 was on EBP's due to having the right subclavian dialysis catheter. She indicated that the resident was on EBP's previously for a wound that the resident had, and once the wound was healed the order for EBP's was discontinued; however, the order for EBP's should not have been discontinued because the resident still needed to be on EBP's due to having the right subclavian dialysis catheter. She indicated that the Director of Nursing advised her that he was placing an order, as well as creating a care plan for EBP's for the resident. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395726 Page 14 of 14