Inspection·August 7, 2025

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for 15 of 65 residents reviewed (Residents 10, 22, 43, 71, 72, 75, 77, 83, 108, 112, 115, 124, 150, 190, 199).Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, 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 have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days.A quarterly MDS assessment for Resident 10 had an ARD of May 2, 2025. There was no previous quarterly or comprehensive MDS assessment in the prior 92 days.A quarterly MDS assessment for Resident 22 had an ARD of June 29, 2025, but it was not completed (Section Z0500B) until July 14, 2025.A quarterly MDS assessment for Resident 43 had an ARD of July 8, 2025, but it was not completed (Section Z0500B) until July 23, 2025.A quarterly MDS assessment for Resident 71 had an ARD of June 26, 2025, but it was not completed (Section Z0500B) until July 11, 2025. A quarterly MDS assessment for Resident 71 had an ARD of July 15, 2025, but it was not completed (Section Z0500B) until July 30, 2025.A quarterly MDS assessment for Resident 72 had an ARD of July 2, 2025, but it was not completed (Section Z0500B) until July 21, 2025.A quarterly MDS assessment for Resident 75 had an ARD of May 5, 2025, but it was not completed (Section Z0500B) until May 21, 2025. A quarterly MDS assessment for Resident 75 had an ARD of May 15, 2025, but it was not completed (Section Z0500B) until May 30, 2025.A quarterly MDS assessment for Resident 77 had an ARD of July 5, 2025, but it was not completed (Section Z0500B) until July 23, 2025.A quarterly MDS assessment for Resident 83 had an ARD of Jun 30, 2025, but it was not completed (Section Z0500B) until July 16, 2025.A quarterly MDS assessment for Resident 108 had an ARD of June 30, 2025, but it was not completed (Section Z0500B) until July 16, 2025.A quarterly MDS assessment for Resident 112 had an ARD of June 30, 2025, but it was not completed (Section Z0500B) until July 15, 2025.A quarterly MDS assessment for Resident 115 had an ARD of June 11, 2025, but it was not completed (Section Z0500B) until June 30, 2025.A quarterly MDS assessment for Resident 124 had an ARD of June 18, 2025, but it was not completed (Section Z0500B) until July 7, 2025.A quarterly MDS assessment for Resident 150 had an ARD of June 30, 2025, but it was not completed (Section Z0500B) until July 15, 2025.A quarterly MDS assessment for Resident 190 had an ARD of June 29, 2025, but it was not completed (Section Z0500B) until July 14, 2025.A quarterly MDS assessment for Resident 199 had an ARD of June 18, 2025, but it was not completed (Section Z0500B) until July 7, 2025.Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 7, 2025 at 8:32 a.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395514 If continuation sheet Page 2 of 9 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 395514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Assessment Instrument, clinical records, and the Minimum Data Set validation report, as well as staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for 3 of 65 residents reviewed (Residents 26, 83, 218). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (federally-mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that comprehensive MDS assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). The MDS assessment validation report from iQIES (a federal government website for the Centers for Medicare and Medicaid), dated May 1, 2025 - August 1, 2023, revealed that the following MDS assessments were submitted late:Resident 26 had a quarterly MDS assessment with a completion date of January 21, 2025, however, was not submitted until July 25, 2025. Resident 83 had a quarterly MDS assessment with a completion date of May 11, 2025, however, was not submitted until June 2, 2025.Resident 218 had a quarterly MDS assessment with a completion date of June 21, 2025, however, was not submitted until July 16, 2025. Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on August 7, 2025 at 8:32 a.m. confirmed that the above comprehensive MDS assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395514 If continuation sheet Page 3 of 9 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 395514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602 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 potential for actual harm Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for six of 65 residents reviewed (Residents 3, 5, 8, 75, 112, 186). 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 N0350A (insulin) was to be coded with the number of days that insulin injections were received during the seven-day assessment period, Section N0415C1 (antidepressant medication) was to be checked if the resident received an antidepressant medication during the seven-day assessment period, Section N0415F1 (antibiotic medication) was to be checked if the resident received an antibiotic medication during the seven-day assessment period, Section N0415G1 (diuretic medication) was to be checked if the resident received an diuretic medication during the seven-day assessment period, Section N0415H1 (opioid medication) was to be checked if the resident received an opioid medication during the seven-day assessment period, and Section N0415K1 (anticonvulsant medication) was to be checked if the resident received an anticonvulsant medication during the seven-day assessment period.Physician's orders for Resident 3 dated July 2, 2025, included an order for the resident to receive 75 milligrams (mg) of Venlafaxine HCl daily for depression. The resident's Medication Administration Record (MAR) for July 2025 revealed that the resident received Venlafaxine daily from July 3 through 31, 2025.A significant change MDS assessment for Resident 3, dated July 24, 2025, revealed that Section N0415C1 was not checked, indicating that the resident did not receive any antidepressant medications during the seven days of the assessment period. Physician's orders for Resident 5 dated December 5, 2022, included an order for the resident to receive 10 mg of Escitalopram daily for depression. The resident's MAR for June 2025 revealed that the resident received Escitalopram daily from June 1 through 30, 2025.A significant change MDS assessment for Resident 5, dated June 11, 2025, revealed that Section N0415C1 was not checked, indicating that the resident did not receive any antidepressant medications during the seven days of the assessment period. Physician's orders for Resident 8 dated July 30, 2024 and May 7, 2025, included orders for the resident to receive 500 mg of Keppra two times a day for adjustment disorder and 8 units of Insulin Glargine subcutaneously (beneath the skin) daily for diabetes mellitus. The resident's MAR for June 2025 revealed that the resident received Keppra two times a day and Insulin Glargine daily from June 1 through 30, 2025.A quarterly MDS assessment for Resident 8, dated June 6, 2025, revealed that Section N0350A and N0415FK1 was not checked, indicating that the resident did not receive any inulin or anticonvulsant medications during the seven days of the assessment period. Physician's orders for Resident 75 dated October 7, 2024, included orders for the resident to receive 7.5 mg of Mirtazapine (antidepressant) at bedtime for an appetite stimulant, 40 mg of Lasix (diuretic) daily for edema (swelling), 200mg of Gabapentin three times a day for neuropathy (nerve pain), and 50 mg of Tramadol every six hours as needed for moderate to severe pain. The resident's MAR for May 2025 revealed that the resident received Mirtazapin, Lasix, and Gabapentin May 1 through 31, 2025, and received Tramadol as needed may 2 through 31, 2025.A quarterly MDS assessment for Resident 75, dated May 15, 2025, revealed that Sections N0415C1, N0415G1, N0415H1, and N0415K1 were not checked, indicating that the resident did not receive any antidepressant, diuretic, opioid, and anticonvulsant medications during the seven days of the assessment period. Physician's orders for Resident 112 dated July 8, 2025, included an order for the resident to receive 50 mg of Tramadol every eight hours as needed for moderate to severe pain. The resident's MAR for July 2025 revealed that the resident received Tramadol as needed on July 11, 14, 15, and 16, 2025. A quarterly Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395514 If continuation sheet Page 4 of 9 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 395514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete MDS assessment for Resident 112, dated July 17, 2025, revealed that Section N0415H1 was not checked, indicating that the resident did not receive any opioid medications during the seven days of the assessment period. Physician's orders for Resident 186 dated June 9, 2025, included an order for the resident to have Bacitracin-Polymixin B ointment applied to her right third finger topically every shift for wound care until it was healed. The resident's MAR for July 2025 revealed that the resident had Bacitracin-Polymixin B applied to her right third finger July 1 through 9, 2025.A quarterly MDS assessment for Resident 186, dated July 5, 2025, revealed that Section N0415F1 was not checked, indicating that the resident did not receive any antibiotic medications during the seven days of the assessment period. An interview with the Registered Nurse Assessment Coordinator on August 6, 2025, at 11:30 a.m. confirmed that assessments for Residents 3, 5, 8, 75, 112, and 186 were coded incorrectly.28 Pa. Code 211.5(f) Medical records. Event ID: Facility ID: 395514 If continuation sheet Page 5 of 9 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 395514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 65 residents reviewed (Resident 83).Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 83, dated July 24, 2025, revealed that the resident was cognitively intact, required substantial assistance from staff with daily care tasks. Physician's orders for Resident 83, dated February 23, 2023, included an order for the resident to receive 500 milligram (mg) of amoxicillin (antibiotic) by mouth daily for prophylaxis for urinary tract infection (UTI) and an order with a start date of January 24, 2023, for one gram (gm) of Methenamine Hippurate (antibiotic) by mouth every morning and at bedtime for UTI prevention due to a history of urinary tract infections with sepsis. There was no documented evidence that a care plan was developed to address Resident 83's individual care and treatment needs related to her use of antibiotic medications. Interview with the Director of Nursing on August 7, 2025, at 2:55 p.m. confirmed that a care plan to address the care needs related to Resident 83's need for antibiotic medication use was not developed and should have been. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. Event ID: Facility ID: 395514 If continuation sheet Page 6 of 9 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 395514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602 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 potential for actual harm Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of 65 residents reviewed (Residents 51, 72, 180). Findings include:A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated May 20, 2025, indicated that the resident was cognitively impaired, was incontinent of bowel, and that she required extensive assistance from staff for daily care needs. Physician's order for Resident 51, dated May 19, 2025, included an order for the resident to receive 8.6 mg Senna Oral, give 4 tablets as needed for constipation if no bowel movement in three days. Physician's order, dated May 19, 2025, was for the resident to receive 10 milligrams (mg) of Bisacodyl Suppository (treats constipation) as needed for constipation if no bowel movement in four days. Review of Resident 51's task record, dated July 2025, revealed that the resident had no bowel movement from July 11-17, 2025 (7 days). Review of Resident 51's Medication Administration Record (MAR), dated July, 2025, revealed no documented evidence that the resident was medicated for constipation until July 16, 2025 (on the 6th day). Review of Resident 51's task record, dated July 2025, revealed that the resident had no bowel movement from July 18-24, 2025. Review of Resident 51's MAR, dated July 2025, revealed no documented evidence that the resident was medicated for constipation until July 23, 2025 (on the 6th day).Interview with Director of Nursing on August 7, 2025 at 11:59 a.m. confirmed that staff were not medicating Resident 51 for constipation per physician's orders and they should have been.A quarterly MDS assessment for Resident 72, dated July 2, 2025, revealed that the resident was cognitively impaired and had diagnoses that included hypertension.Physician's orders for Resident 72, dated June 14, 2025 included an order for the resident to receive 40 mg Propranolol extended release capsule once daily and to hold if the heart rate was less than 60 or the systolic blood pressure (top number) was less than 100.A review of Resident 72's MAR, dated July 2025, revealed that the staff were not assessing the resident's heart rate or blood pressure prior to administering the Propranolol. Interview with the Director of Nursing on August 7, 2025 at 1:34 p.m. revealed that the staff should have been assessing Resident 72's heart rate and blood pressure and documenting the results prior to administering the propranolol and they were not.A comprehensive MDS assessment for Resident 180, dated June 17, 2025, revealed that the resident was cognitively intact and had diagnoses that included renal insufficiency and received dialysis (process to clean the blood of toxins when the kidneys fail).Physician's orders for Resident 180, dated June 10, 2025, included an order for the resident to receive 5 mg Midodrine (treats low blood pressure) and to hold if the systolic blood pressure (SBP) is greater than 130. A review of Resident 180's MAR, dated July and August 2025, revealed that the resident received Midodrine on July 3 with a BP of 140/82, July 6 with a BP of 132/74, July 8 with a BP of 136/70, July 9 with a BP of 132/72, July 18 with a BP of 130/74, July 22 with a BP of 136/84, July 31 with a BP of 132/82, August 1 at 8:00 a.m. with a BP of 134/74 and 3:00 p.m. with a BP of 134/74.Interview with the Director of Nursing on August 7, 2025 at 1:48 p.m. revealed that Resident 180's Midodrine should have been held on the above dates and it was not.28 Pa. Code 211.12(d)(1)(5) Nursing Services. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395514 If continuation sheet Page 7 of 9 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 395514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 locked, compartments for controlled drugs. Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to date an opened multidose vial of tuberculin solution (used to detect tuberculosis infection) in one of two medication storage area refrigerators reviewed (Unit D2). The facility's policy regarding medication storage, dated July 17, 2025, indicated that it is the policy of this facility to ensure all medications housed on their premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations.Manufacturer's instructions for Aplisol solution, dated November 2013, indicated that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.Observations of the facility's medication storage area refrigerator on D2 unit, on August 5, 2025, at 1:45 p.m. revealed an opened and undated vial of Aplisol solution for TB skin testing (to test for tuberculosis).Interview with Licensed Practical Nurse 1 at the time of the observation confirmed that the vial of Aplisol solution was not dated when it was opened and that it should have been.Interview with the Director of Nursing on August 5, 2025, at 3:51 p.m. confirmed that the vial of Aplisol solution should have been dated when opened. 28 Pa. Code 211.9(a)(1) Pharmacy services.28 Pa. Code 211.12(d)(1) Nursing services. Event ID: Facility ID: 395514 If continuation sheet Page 8 of 9 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 395514 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602 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 potential for actual harm Based on review of established infection control guidelines, facility policy, and residents' 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 Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 65 residents reviewed (Resident 5). 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 January 13, 2025, indicated that the facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is currently targeted by CDC may be considered epidemiologically important. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO.A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated June 11, 2025, revealed that the resident was cognitively impaired and was at risk for developing pressure sores.Physician's orders for Resident 5, dated July 30, 2025, included orders for the resident to have 0.125% Dakin's Solution (antiseptic used for cleaning wounds and preventing infection) applied to the pressure ulcer on her left heel topically every day and evening shift.A wound note, dated July 31, 2025, revealed the resident had an unstageable pressure ulcer (wound bed cannot be visualized) on her left lateral heel that measured 6.8 x 8.4 x 0.2 centimeters (cm) and was covered 70% by eschar (a layer of dead tissue, that forms on the skin's surface, often as a scab-like covering over a wound or burn).A wound note, dated August 5, 2025, revealed the resident had an unstageable pressure ulcer on her left lateral foot that measured 1.2 x 1.5 x 0.0 centimeters (cm) and was covered 100% by eschar , and had an unstageable pressure ulcer on her left heel that measured 6.2 x 8.1 x 0.2 cm and was covered 70% by eschar.Observations of Resident 5 on August 4, 2025, at 12:00 p.m., revealed that the resident was in her room, and there was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room. There was no documented evidence that EBP was ordered and care planned for Resident 5 until August 6, 2025.Interview with the Nursing Home Administrator on August 7, 2025, at 4:31 p.m. confirmed that Resident 5's EBP was missed and she should have been in place due to the resident having pressure ulcers.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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395514 If continuation sheet Page 9 of 9