Harmon House Care Center

F-F580, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding physician/responsible party notification.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending July 20 and September 18, 2023, 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

F-F636 on June 19, 2024.

28 Pa. Code 211.5(f) Clinical Records.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0638 Assure that each resident’s assessment is updated at least once every 3 months.

Level of Harm - Minimal harm or 46994 potential for actual harm Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff Residents Affected - Some interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for five of 65 residents reviewed (Residents 2, 17, 47, 59, 72).

The deficiency is being cited as past non-compliance.

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days.

A quarterly MDS assessment for Resident 2, with an ARD of March 13, 2024, was due to be completed by March 27, 2024, but was not signed as completed until March 28, 2024, which was 15 days from the ARD until completion.

A quarterly MDS assessment for Resident 17, with an ARD of March 7, 2024, was due to be completed by March 21, 2024, but was not signed as completed until March 22, 2024, which was 15 days from the ARD until completion.

A quarterly MDS assessment for Resident 47, with an ARD of March 12, 2024, was due to be completed by March 26, 2024, but was not signed as completed until March 27, 2024, which was 15 days from the ARD until completion.

A quarterly MDS assessment for Resident 59, with an ARD of March 13, 2024, was due to be completed by March 27, 2024, but was not signed as completed until March 28, 2024, which was 15 days from the ARD until completion.

A quarterly MDS assessment for Resident 72, with an ARD of March 12, 2024, was due to be completed by March 26, 2024, but was not signed as completed until March 27, 2024, which was 15 days from the ARD until completion.

An interview with Nursing Home Administrator on June 27, 2024, at 10:08 a.m. confirmed that Resident 2's, 17's, 47's, 59's and 72's quarterly MDS assessments were completed late.

Following identification that MDS information was completed late, the facility's corrective actions included:

The MDS assessments cited cannot be resubmitted to the Centers for Medicare and Medicaid Services to correct the late completions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0638 The scheduled MDS assessments within the previous 14 days were reviewed to ensure timely completion.

Level of Harm - Minimal harm or The clinical reimbursement specialist educated the MDS coordinators, and the Nursing Home Administrator potential for actual harm educated the interdisciplinary team members on the timing requirements for completion of MDS assessments. Residents Affected - Some

The Nursing Home Administrator completed audits of MDS submissions twice weekly for two weeks. Audits will continue twice weekly for a total of four weeks then monthly for two months to ensure timely completion.

The findings will be reviewed with the quality assurance performance improvement committee for additional recommendations.

A review of the facility's corrective actions revealed that they were in compliance with

F-F638 on June 19, 2024.

28 Pa. Code 211.5(f) Clinical Records.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or 19102 potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff Residents Affected - Few interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 45 residents reviewed (Residents 38, 73).

Findings include:

The RAI User's Manual, dated October 2023, revealed that Section 16100 psychiatric/mood disorder was to be coded for post-traumatic stress disorder if the resident was diagnosed with that any time during the seven-day look-back period.

A quarterly MDS assessment for Resident 38, dated, June 4, 2024, revealed that Section I16100 was coded, indicating that the resident had a diagnosis of post-traumatic stress disorder.

A social service note, dated May 31, 2024, at 6:59 a.m., indicated that the resident never experienced or witnessed a life threatening or traumatic event.

Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on June 27, 2024, at 1:19 p.m. confirmed that section I16100 of Resident 38's quarterly MDS assessment was coded incorrectly and should have been coded to indicate that

the resident had a traumatic brain injury during the seven-day assessment period.

The RAI User's Manual, dated October 2023, revealed that Section N0415E1 Anticoagulant (medicines that help prevent blood clots) Medications was to be coded if an anticoagulant medication was taken by the resident at any time during the seven-day look-back period.

Physician's orders for Resident 73, dated May 9, 2024, included an order for the resident to receive 2.5 milligrams (mg) of Warfarin (an anticoagulant) at bedtime on Sunday, Monday, Wednesday, and Friday, and 2 mg of Warfarin at bedtime on Tuesday, Thursday, and Saturdays.

Review of the Medication Administration Record (MAR) for Resident 73, dated May 2024, revealed that staff had administered 2 mg and 2.5 mg of Warfarin to the resident on May 9 through 23, 2024.

A quarterly MDS assessment for Resident 73, dated, May 14, 2024, revealed that Section NO415E1 was not coded, indicating that the resident to did not receive an anticoagulant medication during the seven-day look-back assessment period.

Interview with the Director of Nursing on June 27, 2024, at 1:36 p.m. confirmed that Resident 73 received an anticoagulant medication during the seven-day look-back period and should have been coded for an anticoagulant medication.

28 Pa. Code 211.5(f) Clinical Records.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 19102 potential for actual harm Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that Residents Affected - Some the facility failed to follow physician's orders for four of 45 residents reviewed (Residents 17, 37, 40, 46)

Findings include:

The facility's policy regarding medication administration, dated August 14, 2023, indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, document the administration of controlled substances in accordance with applicable law and observe the resident's consumption of the medication(s), and document necessary medication administration/treatment information on appropriate forms.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated May 22, 2024, revealed that the resident was understood, could understand others, was cognitively impaired, and was independent for care.

Physician's orders for Resident 17, dated May 8, 2024, included orders for the resident to have full head-to-toe assessment with vital signs to be completed every shift along with nurse's notes.

A nurse's note for May 10, 2024, at 4:10 a.m. revealed that a full head-to-toe assessment including vital signs was completed for Resident 17.

A review of the health record for Resident 17 revealed no documented evidence that a full head-to-toe assessment was complete, except on May 10, 2024, at 4:10 a.m.

Interview with the Director of Nursing on June 26, 2024, at 1:26 p.m. confirmed that the physician ordered a full head-to-toe assessment for Resident 17 to be competed per shift, and the only documented evidence that it was completed was on May 10, 2024, at 4:10 a.m.

A quarterly MDS assessment for Resident 37, dated April 16, 2024, revealed that the resident was moderately cognitively impaired, received insulin, and had diagnoses that included diabetes. Physician's orders, dated February 18, 2024, included an order for the resident to receive 12 units of Insulin Lispro (insulin) and to hold the insulin if the blood sugar was less than 80 milligrams/deciliter (mg/dL). A care plan, dated April 2, 2024, indicated that staff were to administer medications as ordered by the physician.

Review of Resident 37's Medication Administration Record (MAR), dated April, May and June 2024, revealed that at 7:00 a.m. on April 25, 2024, the resident's blood sugar was 88 mg/dL; on May 14, 2024, the resident's blood sugar was 85 mg/dL; on May 24, 2024, the resident's blood sugar was 89 mg/dL; on May 25, 2024, the resident's blood sugar was 82 mg/dL; on May 26, 2024, the resident's blood sugar was 93 mg/dL; on June 2, 2024, the resident's blood sugar was 84 mg/dL; on June 8, 2024, the resident's blood sugar was 101 mg/dL; and on June 16, 2024, the resident's blood sugar was 87 mg/dL. However, the resident's insulin was held on

the dates listed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0684 Interview with the Director of Nursing on June 27, 2024, at 9:19 a.m. confirmed that Resident 37's insulin should not have been held according to the ordered parameters on the mentioned dates and times. Level of Harm - Minimal harm or potential for actual harm An annual MDS assessment for Resident 40, dated May 14, 2024, revealed that the resident was cognitively intact, was frequently incontinent of urine, and received an antibiotic. Residents Affected - Some

A nursing note, dated May 16, 2024, at 11:06 a.m. revealed that the Certified Registered Nurse Practitioner (CRNP) was in and reviewed the results of the urinalysis (urine test) and culture and sensitivity results (C&S - urine test that identifies specific bacteria and which antibiotics should be used to treat the infection), and a new order was received for 500 mg of Cipro (antibiotic) twice a day for 10 days.

Review of Resident 40's MAR, dated May 2024, revealed that the resident received 500 mg of Cipro twice a day from May 17 through May 27, 2024 (11 days).

Interview with the Director of Nursing on June 27, 2024, at 3:13 p.m. confirmed that Resident 40 received two additional doses of Cipro on May 27, 2024.

A quarterly MDS assessment for Resident 46, dated June 18, 2024, indicated that the resident was cognitively impaired, required assistance with her personal care needs, and had diagnoses that included dementia and hypertension (high blood pressure).

Physician's orders for Resident 46, dated February 17, 2024, included an order for the resident to receive 25 milligrams (mg) of metoprolol tartrate once a day, to be held if the resident's systolic blood pressure (SBP- top number in a blood pressure reading, measures the pressure in the arteries when the heart beats) was less than 100 millimeters of Mercury (mmHg).

Review of the MAR for Resident 46 dated February through June 2024, revealed that on February 19, 2024,

the resident's SBP was 81 mmHg; on February 20, 2024, the resident's SBP was 96 mmHg; on March 20, 2024, the resident's SBP was 95 mmHg; on March 26, 2024, the resident's SBP was 85 mmHg; on April 14, 2024, the resident's SBP was 94 mmHg; on May 8, 2024, the resident's SBP was 96 mmHg; on May 26, 2024, the resident's SBP was 98 mmHg; on June 8, 2024, the resident's SBP was 98 mmHg; on June 15, 2024, the resident's SBP was 94 mmHg, and on June 19, 2024, the resident's SBP was 98 mmHg. Documentation on the MAR revealed that 25 mg of metoprolol tartrate was administered on these dates when it should have been held.

Interview with the Director of Nursing on June 27, 2024, at 9:15 a.m. confirmed that the documentation indicates that Resident 46 was administered metoprolol tartrate on the above-mentioned dates and times when it should not have been administered.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or 41233 potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility Residents Affected - Few failed to ensure that an IV (intravenous - in the vein) dressing change was done as per facility policy for one of 45 residents reviewed (Resident 4).

Findings include:

The facility's policy regarding changing the dressing (a transparent barrier) of midline catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated August 14, 2023, indicated that midline catheter dressings were to be changed weekly and when the integrity of the dressing became compromised (wet, loose or soiled). In addition, the facility policy indicated that staff were to assess the midline insertion site with each medication administration. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection.

A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 18, 2024, revealed that the resident was moderately cognitively impaired and had diagnoses that included bilateral stasis (damaged veins) leg ulcers, bacteremia (a blood infection) and dressing changes. Resident 4's care plan, dated June 20, 2024, indicated that staff would monitor the resident for signs of complications from the IV, such as localized infection or dislodgement.

Physician's orders for Resident 4, dated June 20, 2024, included an order for the resident to receive 4.5 grams of Zosyn (an antibiotic) intravenously (IV - directly in a vein) three times a day for bacteremia until July 14, 2024. Resident 4's Medication Administration Record (MAR) for June 20, 2024, through midnight June 27, 2024, revealed that Zosyn was administered every 8 hours as ordered.

Observations on June 24, 2024, at 2:14 p.m.; June 25, 2024, at 12:51 p.m.; and June 26, 2024, at 9:55 a.m. revealed that the midline dressing on Resident 4's right arm was loose and had lost its integrity.

Interview with Licensed Practical Nurse 2 on June 26, 2024, at 12:05 p.m. confirmed that the midline transparent dressing was visibly loose and and should have been changed.

Interview with the Director of Nursing on June 27, 2024, at 2:57 p.m. confirmed that the dressing was changed on Sunday as per order; however, it was not changed when the integrity of the dressing was compromised, and it should have been.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 41233 potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was Residents Affected - Few determined that the facility failed to ensure that residents received oxygen as ordered by the physician for two of 45 residents reviewed (Residents 8, 70).

Findings include:

The facility's policy regarding oxygen therapy, dated August 14, 2023, indicated that oxygen was to be administered in accordance with physician's orders.

An admission Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 10, 2024, revealed that the resident was understood and understood others, cognitively intact, had diagnoses that included asthma and respiratory failure, and had shortness of breath related to her current condition.

Physician's orders for Resident 8, dated June 10, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils).

Observations of Resident 8 on June 24, 2024, at 11:44 a.m.; June 25, 2024, at 8:15 a.m.; and June 26, at 1:49 p.m. revealed that the resident was in her room receiving oxygen from an oxygen concentrator (electrical machine that concentrates oxygen from the air) that was set at 4 liters per minute.

Interview with Licensed Practical Nurse 3 on June 26, 2024, at 1:49 p.m. confirmed that Resident 8's oxygen flow rate was set at 4 liters per minute and not 2 liters per minute as ordered by the physician.

Interview with the Director of Nursing on June 26, 2024, at 1:58 p.m. confirmed that Resident 8's oxygen flow rate should be set at 2 liters per minute continuously as per physician order, and it was not.

A quarterly MDS assessment for Resident 70, dated June 21, 2024, revealed that the resident was severely cognitively impaired and had diagnoses that included pneumonitis (inflammation in the lungs) and anxiety and was on hospice. Resident 70's current hospice care plan indicated that she had shortness of breath related to her current condition.

Physician's orders for Resident 70, dated June 21, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils).

Observations of Resident 70 on June 24, 2024, at 1:34 p.m.; June 26, 2024, at 1:00 p.m.; and June 27, 2024, at 8:48 a.m. revealed that the resident was in her room receiving oxygen from an oxygen concentrator that was set at 3 liters per minute.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0695 Interview with Licensed Practical Nurse 2 on June 26, 2024, at 12:05 p.m. confirmed that Resident 70's oxygen flow rate was set at 3 liters per minute and not 2 liters per minute as ordered by the physician. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on June 26, 2024, at 12:26 p.m. confirmed that Resident 70's oxygen flow rate should be set at 2 liters per minute continuously as per physician order, and it was not. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 19102

Residents Affected - Some Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 45 residents reviewed (Residents 24, 55).

Findings include:

The facility's policy regarding medication administration, dated August 14, 2023, indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, document the administration of controlled substances in accordance with applicable law, observe the resident's consumption of the medication(s), and document necessary medication administration/treatment information on appropriate forms.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated May 16, 2024, revealed that the resident was cognitively intact, had pain frequently, received pain medication routinely and as needed, and received an opioid (a controlled pain medication).

Physician's orders for Resident 24, dated March 25 and May 10, 2024, included an order for the resident to receive one 10 milligram (mg) tablet of oxycodone (narcotic pain reliever) every four hours as needed for moderate to severe pain.

Resident 24's controlled drug record (a form that accounts for each dose of a controlled drug) for May and June 2024 indicated that one dose of oxycodone was signed out for administration to the resident on May 3 at 4:30 p.m.; May 4 at 5:41 p.m.; May 17 at 6:04 p.m.; May 20 at 3:00 p.m.; May 26 at 9:16 a.m.; June 3 at 9:44 p.m.; June 17 at 9:37 p.m. However, the resident's clinical record, including the MARs and nursing notes, contained no documented evidence that the signed-out dose of oxycodone was actually administered to the resident on these dates and times.

Interview with the Director of Nursing on June 27, 2024, at 1:36 p.m. confirmed that there was no documented evidence that staff administered the signed-out dose of oxycodone to Resident 24 on the above date and time.

A quarterly MDS assessment for Resident 55, dated May 19, 2024, revealed that the resident was cognitively impaired, had pain frequently, received pain medication routinely and as needed, and received a benzodiazepine (a controlled anxiety and antiseizure medication).

Physician's orders for Resident 55, dated April 18, 2024, included an order for the resident to receive 5 milligrams (mg) of diazepam, 5mg/mL (antianxiety medication) daily to wrist and apply 5 mg to wrist every hour as needed for anxiety.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0755 Resident 55's controlled drug record for May 2024 indicated that one dose of diazepam was signed out for administration to the resident on May 8, 2024, at 8:30 p.m. and May 16, 2024, at 2:30 p.m. However, the Level of Harm - Minimal harm or resident's clinical record, including MARs and nursing notes, contained no documented evidence that the potential for actual harm signed-out dose of diazepam was administered to the resident on the above dates and times.

Residents Affected - Some Interview with the Director of Nursing on June 27, 2024, at 4:16 p.m. confirmed that there was no documented evidence that staff administered the signed-out dose of diazepam to Resident 55 on the above dates and times.

28 Pa. Code 211.9(a)(1) Pharmacy Services.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41233 Residents Affected - Few Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications remained properly secured in one of four medication carts reviewed (lower level medication cart) and failed to discard expired in-use stock medications.

The facility's policy regarding medication administration, dated [DATE REDACTED], indicated that the purpose was to provide a method for the safe, accurate administration of oral medications to residents.

Observations of the lower level medication cart on [DATE REDACTED], at 9:17 a.m. revealed that it was unlocked and unattended. The medication cart was facing room [ROOM NUMBER] while the nurse was administering medications to residents in that room. However, the door was shut to the room, which blocked the nurses direct view of the medication cart.

Observations of the top drawer of the lower level medication cart on [DATE REDACTED], at 9:29 a.m. revealed an undated/unmarked medication cup that contained one small, round yellow tablet; one small orange tablet; one white oval capsule; and one large oval white tablet.

Observations in the stock drawer of the lower level medication cart on [DATE REDACTED], at 9:35 a.m. revealed that an opened in-use bottle of Rolaids (medication for an upset stomach) had an expiration date of [DATE REDACTED].

Interview with Licensed Practical Nurse 2 at that time confirmed that the medication cart was unlocked and not in full view when she was in room [ROOM NUMBER] providing medications, that an undated/unmarked medication cup that contained medications in the top drawer of the medication cart should not have been there, and that the expired bottle of Rolaids should not have been in circulation in the medication cart.

Interview with the Director of Nursing on [DATE REDACTED], at 9:30 a.m. confirmed that staff should have kept the unlocked medication cart in full line of view while providing resident medications, that an undated/unmarked medication cup that contained medications should not have been in the top drawer of the medication cart, and a bottle of Rolaids that expired in 2021 should not have been in the medication cart.

28 Pa. Code 211.9(a)(1) Pharmacy Services.

28 Pa. Code 211.12(d)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48809

Residents Affected - Few Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was prepared and served under sanitary conditions, in accordance with professional standards for food service safety.

Findings include:

The facility's policy regarding food and nutrition services, dated August 14, 2023, indicated that employees will wear a clean, appropriate hairnet/hair restraint, and that beards and facial hair will be contained.

Observations in the main kitchen on June 25, 2024, at 1:50 p.m. revealed that Dietary Aide 4 did not have a beard guard covering his beard.

Interview with the Dietary Manager on June 25, 2024, at 1:55 p.m. confirmed that Dietary Aide 4 did not have

a beard guard on to cover his beard and should have.

Observations of sanitizer on June 26, 2024, at 1:15 p.m. revealed that the sanitizer level in the three-compartment sink was 500 parts per million (ppm).

A review of the three-compartment sink sanitizer log revealed that the sanitizer level was 500 ppm on February 1, 2024; February 2, 2024; March 3, 2024; March 7, 2024; March 8, 2024; March 12, 2024; March 18, 2024; and March 27-31, 2024.

Manufacturer instructions for [NAME] Sani-Quat no-rinse sanitizer revealed that the sanitizer level must be 200-400 ppm.

Safety Data sheet for [NAME] Sani-Quat no-rinse sanitizer revealed that sanitizer at higher than recommended strength can cause harm.

Interview with Nursing Home Administrator on June 27, 2024, at 8:42 a.m. confirmed that the sanitizer level should be from 200-400 ppm and was not on the above dates.

28 Pa. Code 201.18(e) (2.1) Management.

28 Pa. Code 211.6(f) Dietary Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 19102

Residents Affected - Few 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 September 18 and October 25, 2023, and July 27, 2023, 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 27, 2024, identified repeated deficiencies regarding notification of the physician, quality of care, issues with intravenous therapy, preventing issues with the accountability of controlled medications (drugs with the potential to be abused), ensuring medications were properly stored/labeled, ensuring that food was prepared/stored/served under sanitary conditions, and following infection control practices.

The facility's plan of correction for a deficiency regarding notifying the physician/responsible party about changes in condition, cited during the survey ending September 18, 2023, 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

F-F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.

The facility's plan of correction for a deficiency regarding a failure ensure that intravenous therapy was completed correctly, cited during the survey ending on July 20, 2023, 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

F-F694, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding intravenous therapy.

The facility's plan of correction for a deficiency regarding the failure to account for controlled medications, cited during the survey ending July 20 and September 18, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0867 The facility's plans of correction for deficiencies regarding storage and labeling of medications, cited during

the survey ending July 20, 2023, revealed that the facility developed plans of correction that included Level of Harm - Minimal harm or completing audits and reporting the results of the audits to the QAPI committee for review. The results of the potential for actual harm current survey, cited under

F-F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storage and labeling of medications. Residents Affected - Few

The facility's plan of correction for a deficiency regarding appropriate food storage cited during the survey ending October 25, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F812, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding preparing/storing/serving food under sanitary conditions.

The facility's plans of correction for deficiencies regarding infection control practices, cited during the survey ending July 20, 2023, 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

F-F880.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 395726 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395726 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harmon House Health & Rehab Center 601 South Church Street Mount Pleasant, PA 15666

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 41233 potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was Residents Affected - Few determined that the facility failed to ensure that proper infection control practices and techniques were followed during the administration of medications.

Findings include:

The facility's policy regarding hand hygiene and medication administration through certain routes, dated August 14, 2024, indicated that staff were to perform hand hygiene prior to administering medications and specifically prior to eye drop administration.

Physician's orders for Resident 15, dated July 6, 2023, included an order for the resident to receive Restasis (medication for dry eyes) one drop in each eye twice a day.

Observations during medication administration on June 26, 2024, at 8:52 a.m. revealed that Licensed Practical Nurse 2 prepared Resident 15's medications and without performing hand hygiene she administered the resident her po (by mouth) medications. Then without performing hand hygiene once again,

she administered the resident her eye drops.

Interview with Licensed Practical Nurse 2 on June 26, 2024, at that time confirmed that she should have performed hand hygiene prior to administering Resident 15's medications and again before administering the resident her eye drops.

Interview with the Director of Nursing on June 27, 2024, at 9:30 a.m. confirmed that Licensed Practical Nurse 2 should have performed hand hygiene prior to administering the resident's medications and again before administering the resident her eye drops.

28 Pa. Code 211.12(d)(1) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 395726