Health inspection·March 11, 2025

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review and staff interview, it was determined that the facility failed to implement treatment and services for mobility for one of two residents reviewed (Resident CR1). Residents Affected - Few Findings include: Closed clinical record review for Resident CR1 revealed a physical therapy Discharge summary dated [DATE], that stipulated that her wheelchair seat was too high for her feet to touch the ground, and she was unable to self-propel. The documentation indicated that there was a representative from an outside resource that assessed the situation, and there were adjustments pending. Resident CR1's closed clinical record contained no evidence of any further adjustments to Resident CR1's wheelchair. A physical therapy Discharge summary dated [DATE], noted the discontinuation of treatment as the patient discharged to hospital. Resident CR1's closed clinical record did not indicate that she was discharged to the hospital in December 2024. A physician's order dated December 11, 2024, instructed physical therapy to continue treatment up to 20 visits in 30 days. Resident CR1's closed clinical record did not contain evidence that the physical therapy staff assessed or treated Resident CR1 on or after December 11, 2024. The facility transferred Resident CR1 to the hospital on January 6, 2025, and discharged Resident CR1 from the facility on January 15, 2025. Interview with Employee 1 (physical therapy assistant) on March 11, 2025, at 1:30 PM revealed that Resident CR1 had decreased mobility of her lower extremities with contractures of her knees. Resident CR1 propelled herself in her wheelchair using her feet in the hallways; however, the height of her initial wheelchair seat allowed her knees to remain in a bent position as she propelled her wheelchair. Resident CR1 received a customized wheelchair to allow the stretching of her legs, which lessened the ability of her feet to come in complete contact with the floor. The facility evaluated the chair again and determined that another frame would lower the seat of the wheelchair slightly to increase the contact her feet would have with the floor and, potentially, improve her ability to self-propel. The interview confirmed that the facility had no further evidence that Resident CR1's chair was modified to improve the contact her feet had with the floor. The interview also confirmed that the facility had no documentation that Resident CR1 received skilled physical therapy services after December 6, 2024. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395356 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395356 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Guy and Mary Felt Manor, Inc 110 East Fourth Street Emporium, PA 15834 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)