Health inspection·January 13, 2026

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide the resident/resident's responsible party with complete information and supplies in preparation for discharge for one of 12 residents reviewed (Resident 1) who were discharged to home. This deficiency was cited as past non-compliance. Findings include:The facility's discharge planning policy, August 14, 2025, indicated that when a resident's discharge was anticipated, the facility would develop and implement a discharge plan that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable re-admissions.An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 21, 2025, revealed that the resident was cognitively intact, was incontinent of bowel and bladder, was at risk for developing pressure ulcers, and had no current pressure ulcers.A wound note, dated December 4, 2025, revealed the resident developed full thickness moisture associated skin damage on the sacrum that measured 6.2 x 3.6 x 0.2 centimeters (cm). A physician's order, dated December 5, 2025, included an order for the sacrum (area located at the base of the spine) to be cleansed with soap and water, patted dry, and Medi-honey (honey based treatment used to heal wounds and prevent infection) applied to the area once a day. The Treatment Administration Record (TAR) for Resident 1 for December 2025 revealed that Medi-honey was applied to the resident's sacrum daily on December 5 and 6, 2025.A nursing note, dated December 6, 2025, at 2:13 p.m. revealed the resident was discharged to home. The medications were reviewed with the resident's family member and the discharge instructions were provided.The discharge instructions for Resident 1, dated December 6, 2025, revealed that the resident was being discharged home with home health and there was no indication that the resident was receiving wound care (wound care was marked N/A). The drug disposition (indicates which medications were sent with the resident upon discharge) form, undated, revealed that medications were sent home with the resident; however there was no documented evidence that Medi-honey was sent with the resident. Interview with the Nursing Home Administrator on January 13, 2026, at 3:31 p.m. confirmed that there was no documented evidence that Resident 1 or his family was provided Medi-honey or instructions for wound care upon discharge.Following identification that the resident was discharged home without receiving Medi-honey or wound care instructions, the facility's corrective actions included:The facility called the family after discharge to review discharge instructions/wound care orders.An audit was performed to ensure that all residents who have wounds and are anticipating a discharge within the next seven days had appropriate paperwork prepared.Education was provided to the Nursing Supervisor and licensed staff regarding accurate treatment orders and having supplies available until home health care was established.Audits were completed two days a week for two weeks, then monthly for two months to enasure all residents have received adequate and appropriate discharge instructions. Results of the audits Page 1 of 5 395726 395726 01/13/2026 Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

F 0627 Level of Harm - Minimal harm or potential for actual harm would be reviewed by the QAPI committee for two months.A review of the facility's corrective actions revealed that they were in compliance with F627 on December 29, 2025.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Residents Affected - Few 395726 Page 2 of 5 395726 01/13/2026 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of established infection control guidelines and review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination during a COVID-19 outbreak for three of 12 residents reviewed (Resident's 4, 10, and 11). Findings include: CDC guidance on infection control guidelines and implementation of Personal Protective Equipment (PPE) use in nursing homes to prevent the spread of COVID-19 indicated that early detection of signs and symptoms of COVID-19 is key to minimize transmission throughout the facility, as it enables Healthcare Personnel (HCP) to implement mitigation strategies early. As part of the facility's routine assessment of residents for signs and symptoms of illness, it is important to assess and monitor for any signs and symptoms of COVID-19 regardless of their vaccination status. Older adults with SARS-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. It is important to assess for other COVID-19 symptoms such as fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea. A testing plan is an important component of outbreak response and management to ensure the timely identification of individuals who may be infectious with COVID-19.Regardless of vaccination status, testing recommendations include testing anyone with even mild symptoms of COVID-19 as soon as possible (fever, cough, sore throat, malaise, headache, muscle pain without shortness of breath, dyspnea, or abnormal chest imaging). HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services (housekeeping), laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). Review of electronic event reports, submitted by the facility to the Department of Health, between December 25, 2025, and January 9, 2026, revealed that a total of 18 residents developed COVID-19 infection between these dates. Interview with the Nursing Home Administrator at the time of the on-site visit on January 13, 2026, revealed that they had 11 active cases of COVID-19 infection in the building and surgical masks were to be worn on the units unless entering rooms with COVID-19 positive residents at which time an N-95 mask would be used. A physician's order for Resident 4, dated September 5, 2025, indicated that the facility may test for COVID-19 as needed for COVID-19 per protocol. (If resident refused, document test offered and risks/benefits discussed).A physician's order for Resident 4, dated December 30, 2025, included orders for Isolation/Transmission-Based Precautions: Combined Droplet/Contact Precautions/Isolation related to: COVID-19.A nursing note for Resident 4, dated December 10, 2025, at 7:10 p.m. indicated that Resident 4 was running a low grade 99.4 degree Fahrenheit (F) fever earlier this AM. Resident reporting body aches, chills, shortness of breath and a dry Residents Affected - Few 395726 Page 3 of 5 395726 01/13/2026 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 cough. A nursing note for the resident, dated December 26, 2025, at 11:15 a.m. indicated that Resident 4 complained of a headache, fatigue, general malaise and cough. Vital signs were obtained and resident noted to have temperature of 100.4 F. The rapid covid swab positive.Interview with the Infection Preventionist (IP) and the Director of Nursing on January 13, 2026, at 3:06 p.m. indicated that typically they would test residents with COVID-19 symptoms, but that would depend on the practitioner. There was no positive COVID-19 cases in the building at the time and resident was seen by a practitioner. The Director of Nursing did confirm that Resident 4 had standing orders to test for COVID-19 as needed, and a test was not performed on December 10, 2025. A physician's order for Resident 10, dated September 5, 2025, indicated that the facility may test for COVID-19 as needed for COVID-19 per protocol. (If resident refused, document test offered and risks/benefits discussed). A physician's order for Resident 10, dated January 4, 2026, included orders for Isolation/Transmission-Based Precautions: Combined Droplet/Contact Precautions/Isolation related to: COVID-19. A nursing note for Resident 10, dated January 1, 2026, at 4:24 p.m. indicated that staff reported the resident had a cough and congestion. A nursing note for the resident, dated January 2, 2026, at 12:39 a.m. indicated that the resident was in bed and reported a cough and congestion with general malaise. A nursing note for the resident, dated January 4, 2026, at 12:00 a.m. indicated that the resident was being monitored for cold symptoms and had complaints of cough and congestion. Her skin was pale in color and she had remained in bed for the past two days due to not feeling well. A nursing note for the resident, dated January 4, 2026, at 12:15 p.m. indicated that the resident continued to not feel well. She had symptoms of cough, congestion, and malaise. The Certified Registered Nurse Practitioner (CRNP) was notified, and a new order was obtained for a rapid covid swab and the rapid covid swab resulted positive. Interview with the Infection Preventionist (IP) and the Director of Nursing on January 13, 2026, at 3:06 p.m. indicated that typically they would test residents with COVID-19 symptoms, but that would depend on the practitioner. The Director of Nursing did confirm that Resident 10 had standing orders to test for COVID-19 as needed. The Director of Nursing did not either agree or disagree that testing Resident 10 for COVID-19 was necessary, despite the facility having active cases of COVID-19 in the building at the time the resident was symptomatic. A nursing note for Resident 11, dated January 4, 2026, at 11:20 a.m. indicated that the resident reported not feeling well. On assessment, a moist productive cough was observed. She reported body aches and malaise, and expiratory wheezing was heard when assessing lung sounds. The CRNP was notified, and a new order was obtained for a rapid covid swab and the rapid covid swab resulted positive. A physician's order for Resident 11, dated January 4, 2026, included orders for Isolation/Transmission-Based Precautions: Resident receives all care and services in room while on Transmission-Based Precautions/Isolation. Observations in the North Hall for rooms 120-127 on January 13, 2026, at 12:34 p.m. revealed that Laundry Aide 1 delivered personal clothing to Resident 10 and Resident 11 in room [ROOM NUMBER] wearing only a surgical mask. This room was identified as a COVID-19 positive room with signage outside the room for droplet precautions and had an isolation station on the door containing N-95 masks, gowns, gloves and an eye shield. Interview with Laundry Aide 1 at 12:36 p.m. confirmed that he should have gowned up before he entered the room, or should have placed the clothes on the hook on the outside of the door. He stated he probably should have worn an N-95 mask when entering the room but was not sure where they were. He then stated he did see that they were available in the isolation stations on the door. Interview with the Infection Preventionist (IP), on January 13, 2026, at 3:06 p.m. confirmed that the process for all staff (any discipline) entering a COVID-19 positive room would be to donn gloves, an N-95 mask, eye protection and a gown. She confirmed that all staff are fit tested for a mask and they 395726 Page 4 of 5 395726 01/13/2026 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 are to use that size of mask when entering a room with COVID-19 positive residents. The IP confirmed that Laundry Aide 1 should have donned a gown, N-95 mask, gloves and eye protection prior to entering room [ROOM NUMBER]. The Director of Nursing and NHA had confirmed that all staff had received education on COVID-19 precautions. 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.---- Residents Affected - Few 395726 Page 5 of 5