Health inspection·January 9, 2025

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and documents, and resident and staff interviews, it was determined that the facility failed to ensure that the residents are able to voice their concerns at the meetings, and that the meeting concerns are recorded for timely follow-up and resolutions to resident concerns for seven of seven Resident Council attendants (Residents R9, R14, R56, R62, R67, R73, and R85). Residents Affected - Some Findings include: Review of a facility policy entitled Resident Council Policy dated 9/2024, indicated that the Life Enrichment Director or designee may attend the Resident Council Meeting to act as a liaison between the group and the facility if requested by the Council. Any additional facility personnel will attend the meeting upon request of the residents. The Activity Director will attempt to accommodate the resident recommendations to the extent practicable and provide follow-up to the Resident Council. Resident Council will document minutes of each meeting along with attendance on the Resident Council Meeting Minutes Form. Resident issues or concerns will be documented on the Resident/Family Concern Form and forwarded to the facility Administrator for the appropriate follow-up. If a particular resident is voicing a concern versus a group concern, the resident may or may not include their name. Once the respective department has addressed the Resident/Family Concern and document the outcome, the form is returned to the Life Enrichment Director to file with the Resident Council Minutes. Resident Council minutes from 10/28/24, revealed no concerns with administration, nursing, dining services, maintenance, laundry, social services, therapy, business office, life enrichment. Food committee-residents stated they would like to have different snacks available. We now have more option for snack now *Nutri grain bars *Fig bars. Resident Council minutes from 11/25/24, revealed resolutions old business-Review of Previous Meeting, Outstanding Issues and Resident Council Departmental Response Forms Resolutions from last meeting (from the concern forms): Administration issue/concern: No issues. Resolution: No concern. Nursing issue/concern: Cellphones in hallways. Resolution: No issues, residents stated they have not been seeing staff on their phones. Dining Services issue/concern: Resolution: No issues residents stated they enjoy eating in the dining room. Maintenance issue/concern: No issues. Laundry issue/concern: Resolution: No issues. Page 1 of 12 395536 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0565 New Business Level of Harm - Minimal harm or potential for actual harm Administration-Residents stated the administrator is great. Residents Affected - Some Nursing-No concerns. Residents stated staffing is better, aids should knock before entering rooms stated residents. Most aids do knock on the doors. Dining Services-Residents stated they enjoy eating in dining room. Maintenance-Residents stated he is great, doing a great job, no complaints. Laundry-no concerns resident stated there not missing any items this month. Social Services-no concerns. Therapy-Residents stated therapy is good at what they do. Business office-No concerns. Food Committee-residents stated they're happy to now get chef salads as a substitute. Resident Council minutes from 12/30/24, revealed resolutions old business-Review of Previous Meeting, Outstanding Issues and Resident Council Departmental Response Forms Resolutions from last meeting (from the concern forms): Administration issue/concern: No issues. Nursing issue/concern: Cellphones use in hallways. Resolution: No cell phone use in hallways. Dining Services issue/concern: Residents stated they want more residents to eat in the dining area. Resolution: We have more residents eating in dining area at this current time. Maintenance issue/concern: No issues. Laundry issue/concern: No issues. New Business Administration-No concerns. Residents stated the administrator is doing great. Nursing-No concerns. Residents stated staffing is better. Call lights are getting better. Resident did state there is some use of cell phones in hallways staff mostly agency aids. Dining Services-no concerns residents enjoy eating in dining room. Residents stated there are more residents that come down to dining area feels like family eating together. Maintenance-No concerns. Residents are sad to see him leave. Laundry-No concerns. Residents stated laundry is not an issue this month. 395536 Page 2 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0565 Social Services-No concerns. Level of Harm - Minimal harm or potential for actual harm Therapy-No concerns. Residents state therapy is great. Business office-No concerns. Residents Affected - Some Life Enrichment-Residents would like to change evening bingo times. Life enrichment director will work on doing that. Food Committee-No complaints for food committee residents stated food is good. During a Resident Council meeting on 1/07/25, between 1:00 p.m. and 1:35 p.m., seven resident council attendants (Residents R9, R14, R56, R62, R67, R73, and R85) elicited concerns that their Resident Council monthly meeting concerns are not followed up by each department. Residents further indicated they never hear back from the facility and/or see any positive resolution from their concerns. Residents revealed in the past three months (October, November, and December of 2024) concerns for call bell response times (times revealed by residents ranged between 30 minutes and one hour time period for staff to respond to a call bell), snack availability (residents revealed that snacks are not available often, either the dietary department does not supply them to the floors and/or staff state there are none available and will not bring any to the residents' rooms), food quality, palatability, and temperature of resident meals, linen and resident care supplies availability (residents revealed wash cloths, towels, sheets, paper towels, soap, and incontinence products are not available daily) and housekeeping do not clean their rooms often enough due to lack of staff, .were voiced each month and not addressed by the facility and/or resolutions communicated back to the Resident Council residents. During an interview on 1/07/25, at 3:00 p.m. the Activity Director revealed that no concerns, other than some dietary issues, were ever mentioned by the residents in the past three months of Resident Council (October, November, and December of 2024). During an interview on 1/08/25, at 3:00 p.m. the Social Services Director revealed that no concerns from Resident Council were provided to him/her to follow up with each department for the past three months (October, November, and December of 2024). The Nursing Home Administrator indicated on 1/08/25, at 2:10 p.m. that the Social Services Director would be the facility person to follow up on Resident Council concerns. Review of Resident Council meeting notes from October, November, and December 2024, revealed a lack of evidence of resident contribution and/or participation in the Resident Council meetings and evidence regarding how the facility responded to any resident concerns. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management 395536 Page 3 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, staff and resident interviews and observations, it was determined that the facility failed to provide adequate housekeeping services to maintain a clean and sanitary environment for 14 of 94 resident rooms (Rooms 207, 209, 210, 217, 220, 223, 224, 226, 303, 307, 310, 319, 321, and 325 ), and for one of two dining rooms. Findings include: Facility policy, General/Routine Environmental Cleaning and Disinfection Policy dated 9/2024, revealed proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water. Process for Environmental cleaning and disinfection includes: working from clean to dirty; working from top to bottom. Cleaning and disinfection of environmental surfaces immediately if surface(s) are visibly soiled. Daily cleaning and disinfection for high touch surfaces in resident rooms. Household surfaces should be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled (floors, tabletops, resident care areas, dining rooms, common areas, shared shower rooms and bathrooms, hair salons, activities, etc). Horizontal surfaces with infrequent hand contact (e.g., windowsills and hard-surface flooring) in routine patient care areas require cleaning on a regular basis, when soiling or spills occur, and when a patient is discharged from the facility. Cleaning of walls, blinds, and window curtains is recommended when they are visibly soiled. Interviews with Residents R9, R56, R62, R67, R73, and R85 on 1/07/25, at 1:00 p.m revealed the residents feel the facility and their rooms are unsanitary and not cleaned sufficiently and/or often enough. Observations on 1/06/25, from 11:25 a.m. through 2:30 p.m. of resident rooms revealed the following: Rooms 220, 223, 224 and 226: the floors were dirty with dried stains, debris, trash and what appeared to be food particles. The bathroom of room [ROOM NUMBER] was noted to be without toilet paper. Observations on 1/06/25, 1/07/25, and 1/08/25, at approximately 11:30 a.m of room [ROOM NUMBER] revealed a lancet (a small medical device that releases a needle to prick the skin and obtain a blood sample), medication cup, used band-aid, gauze with blood stain, and a wound vac strap laying on the floor under and near the window bed. A dried brown liquid was also observed on the wall and floor near the window bed. Observations of room [ROOM NUMBER], on same dates as noted above, revealed brown stains on the privacy curtain, and room [ROOM NUMBER] with a lancet, nebulizer, and a yellowish-brown dried liquid under the resident's bed by the door. The Nursing Home Administrator (NHA) confirmed the above observations in rooms [ROOM NUMBER] on 1/08/25, at 11:55 a.m. that were unsanitary, and the rooms were not cleaned sufficiently. Review of housekeeping form entitled housekeeping resident room checklist, which all housekeeping staff fill out ensuring all rooms get cleaned and stocked completely, revealed that housekeeping staff should refill paper towels and soap dispensers. 395536 Page 4 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observations on the second floor east hall resident care area on 1/06/25, at about 4:15 p.m. revealed that 2 east hallway hand sanitizer dispensers were empty. Observation of room [ROOM NUMBER] restroom revealed no paper towels or toilet paper, room [ROOM NUMBER] had no soap in the soap dispenser, room [ROOM NUMBER] had no paper towels or toilet paper, and room [ROOM NUMBER] had no paper towels. During an interview with Licensed Practical Nurse Employee E2, at the time of the observations, it was confirmed that the restrooms observed and hallway hand sanitizer were not stocked with the supplies for resident use. Observations of the 3rd floor east hall resident care area on 1/07/25, at about 9:30 a.m., revealed that the 3 east hallway hand sanitizer dispensers were empty. Observation of room [ROOM NUMBER] restroom revealed no paper towels in the dispenser, room [ROOM NUMBER] had no toilet paper or paper towels, and room [ROOM NUMBER] had no paper towels. During an interview with Registered Nurse Employee E3 at the time of observations, it was confirmed that the restrooms observed and hallway hand sanitizer dispensers were not stocked with the supplies for resident use. An interview conducted with the NHA 1/08/25, at approximately 2:30 p.m. revealed that supplies should be stocked for resident use in resident rooms, restrooms, and resident care areas. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(2.1) Management 395536 Page 5 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to comprehensively assess pressure ulcers/injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of 21 residents reviewed (Resident R42). Residents Affected - Few Findings include: A facility policy Pressure Injury Prevention and Treatment Policy dated 9/2024, revealed Residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. New pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable. Pressure injuries identified will be assessed initially and at least weekly thereafter, until closed. All assessments will include the following elements: Location and stage [Stage one-nonblanchable redness of an area. Stage Two-shallow open ulcer with a red or pink wound bed without slough or bruising. Stage Three-full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle is not exposed and slough (yellow, white, or gray material that can be dry or moist and is a result of dead cells and bacteria accumulating in a wound) may be present but does not hide the depth of tissue loss. Stage 4-full thickness loss with exposed bone, tendon, or muscle. Unstageable-slough and/or eschar (dead tissue that eventually will fall off from the skin), pressure ulcer known but not stageable due to coverage of wound bed by slough and/or eschar]. (if pressure injury), Size (perpendicular measurements of the greatest extent of length and width of the ulceration) depth and the presence, location and extent of any undermining of tunneling/sinus tract, Exudate if present: type (such as purulent/serous), color, odor and appropriate amount, Pain, if present: nature and frequency (e.g., whether episodic or continuous), Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation [new tissue that forms in the body during the healing process of wounds] tissue, maceration [process of softening or breaking down]) as appropriate, Any evidence of infection. Resident R42's clinical record revealed an admission date of 6/05/24, with diagnoses that included osteomyelitis of left ankle (inflammation of ankle bone caused by infection), gangrene (dead tissue caused by an infection or lack of blood flow), bacteremia (bloodstream infection), and urinary tract infection. Resident R42's hospital records dated 5/28/24, revealed Resident R2 had a stage three pressure injury to the coccyx (a small triangular bone at the base of the spinal column) with assessment documented as 2 cm diam [centimeter diameter], 0.2 cm deep with areas of scattered moist yellow and tan slough on red base small amt serous [clear or slightly yellow fluid] tan drainage, wound located with in bright red macerated, weeping skin, solid redness with macules [a flat, distinct discolored area of skin less than 1 cm wide] and papules [a small, raised, solid pimple or swelling] around the edges. Resident R42's clinical record for the day of admission to the facility, 6/05/24, revealed Resident R42's pressure injury to the coccyx assessment documented as Stage 2 to Coccyx 1.5 cm x 0.5 cm. Resident R42's clinical record dated 6/11/24, by a Certified Registered Nurse Practitioner (CRNP) revealed Resident R42's pressure injury to the coccyx/sacrum assessment documented as Stage/Severity: Unstageable, Wound Status: Present on Admission, Odor Post Cleansing: None, Size: 7 cm x 7 cm x 0.1 cm. Calculated area is 49 sq cm. Wound Base: 50-74% granulation, 50-74% eschar, Wound Edges: 395536 Page 6 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Attached, Periwound: Macerated, Exudate: Moderate amount of Serosanguineous [drainage containing blood and serum, the clear liquid part of blood]. During an interview on 1/09/25, at 10:40 a.m. the Infection Control Licensed Practical Nurse (ICLPN) confirmed the facility failed to accurately assess and document Resident R42's coccyx on admission to the facility 6/05/24. The ICLPN further confirmed Resident R42's coccyx wound was inaccurately documented as a stage two pressure ulcer, and lacked a comprehensive assessment of the pressure injury as noted prior, Stage 2 to Coccyx 1.5 cm x 0.5 cm, due to the resident was documented with a stage three coccyx pressure ulcer with macerated, weeping skin and macules, papules around the edges at the hospital prior to admission. 28 Pa. Code 211.5 (f)(ii)(iii)(ix) Medical records 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395536 Page 7 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on resident interviews and observations, it was determined that the facility failed to provide sufficient nursing staff to promote the physical and mental well-being and meet the needs of nine of 24 residents interviewed (Residents R149, R19, R226, R9, R56, R67, R62, R73, and R85). Findings include: During interviews on 1/06/25, from 10:05 a.m. through 1:00 p.m. revealed that Residents R149, R19 and R226 expressed concerns of poor call bell response times, indicating that they often had to wait nearly an hour after activating the call bell, to have their needs met. Obervations on 1/06/25, at 2:17 p.m. revealed an activated call light for Resident R226. The call light remained unaddressed until 2:30 p.m. During interview at 2:25 p.m., Resident R226 stated they activated the call light as they had been left on a bedpan which was causing considerable discomfort while waiting for assistance. At this time, staff members were observed seated at the nursing station where the call bell system was alarming audibly and visually lighted. Interviews during the Resident Council meeting on 1/07/25, between 1:00 p.m. and 1:30 p.m., revealed six out of seven alert and oriented residents in attendance with concerns related to staff not responding to their call bells timely. Resident R62 indicated that it could take 45 minutes for his/her call bell to be answered and, staff are typically outside or near his/her door due to he/she can hear them. Resident R9 indicated that he/she will wait for 30 minutes to receive incontinence care after placing his/her call bell on. Resident R9 further indicated if he/she does not get his/her call bell answered by the end of dayshift, it could take longer due to the new shift coming on. Residents R56, R67, R73, and R85 indicated they wait 30 minutes when their call bell is placed on to be responded to by staff. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(4)(5) Nursing services 395536 Page 8 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 clinical records and facility policy, observations, and staff interviews, it was determined that the facility failed to properly reorder and store medications for two of eight residents reviewed during medication pass observations (Residents R72 and R73). Findings include: Review of the facility policy entitled Medication Shortages/Unavailable Medications last revised 8/01/2024, revealed that upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication form the pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately notify the pharmacy. Resident R72's clinical record revealed an admission date of 7/23/24, with diagnoses that included history of falls, fracture of the left femur, and aftercare for joint replacement therapy. R72 had a physician's order for Oxycodone (pain medication) 5 milligrams (mg) every 6 hours as needed for pain with a start date of 10/14/24, and last administered 11/04/24. Observation of medication administration on 1/06/25, at 3:55 p.m. revealed that Licensed Practical Nurse (LPN) Employee E2 attempted to obtain oxycodone for Resident R72 for pain upon resident request. Upon attempting to administer oxycodone per order, there was no medication card in the cart to fulfill the order. During an interview at that time, LPN Employee E2 confirmed that there was no medication card, the medication would have to be obtained through the Omnicell machine. The last time the medication was administered per record was 11/04/24, and the order was not resubmitted to the pharmacy for use. Resident R73's clinical record revealed an admission date of 8/13/22, with diagnoses that included Type 2 Diabetes (a long term condition in which the body has trouble controlling blood sugar levels due to the pancreas not making enough insulin), depression, heart failure, and history of a cerebral infarction (blocked blood flow to the brain causing brain tissue to die). R73 had a physician's order for Furosemide (medication to help excrete fluids) 20 mg by mouth daily. Observation of medication administration on 1/07/25, at 9:15 a.m. revealed that Registered Nurse (RN) Employee E3 attempted to administer Furosemide 20 mg per physician's order during morning routine medication pass. The medication cart did not contain Furosemide for resident use and the medication was not reordered from the pharmacy after the last medication was administered. During an interview at that time, RN Employee E3 confirmed that there was no medication card for Furosemide because it was not reordered from the pharmacy after the last pill was given from the card. The medication would have to be obtained through the Omnicell machine. During an interview on 1/08/25, at approximately 1:30 p.m. the Director of Nursing, and Nurse Supervisor confirmed that the medications were not reordered from the pharmacy as they should have been and were not available for use as required in the medication carts for Residents R72 and R73. 395536 Page 9 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0761 28 Pa. Code 201.18(b)(1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Residents Affected - Few 395536 Page 10 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

F 0809 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to routinely offer nutritious snacks as desired for six of seven residents interviewed about snacks (Residents R9, R14, R56, R67, R73, and R85). Findings include: A facility policy, Meal Times and Frequency Policy, dated 9/2024, revealed there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal (dinner) and breakfast the following day if a resident group agrees to this meal span. A nourishing snack means items from the basic food groups, either singly or in combination with each other. Adequacy of the snack will be determined both by individuals in the group and evaluating the overall nutritional status of those in the facility. Interviews with alert and oriented Residents R9, R14, R56, R67, R73, and R85 on 1/07/25, at 1:00 p.m. revealed that snacks are not routinely offered in the evening, and they would like to receive an evening nutritious snack. Observations on 1/07/25, at 9:45 a.m. revealed one fruit bar, five oatmeal cookies, one single serve applesauce container, and one can of chicken soup in the third-floor cupboard at the nurses station. Nursing Assistant Employee E1 confirmed that these were the snacks available for the 54 residents who reside on the third floor for the past midnight shift and current day shift. 28 Pa. Code 211.12 (d)(1) Nursing services 395536 Page 11 of 12 395536 01/09/2025 Edison Manor Nursing & Rehabilitation Center 222 West Edison Avenue New Castle, PA 16101

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 facility policy, observations, and staff interviews, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for two of two resident units (200 and 300 units). Residents Affected - Some Findings include: A facility policy, Transmission-Based Precautions and Isolation Policy, dated 9/2024, revealed Enhanced Barrier Precautions (EBP) - EBP are intended to prevent transmission of multi-drug resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high risk residents. EBP are indicated for high contact care activities for residents with chronic wounds and indwelling devices (such as central lines, urinary catheters, and trachs) and for all those colonized or infected with a MDRO currently targeted by the CDC. Other MDROs may be included at the discretion of the facility Infection Control Committee unless required by state guidance. Observations on 1/07/25, at 12:05 p.m. revealed Certified Registered Nurse Practitioner (CRNP) completing a wound assessment in Resident R42's room without donning (putting on) a gown. An interview with the Infection Control Licensed Practical Nurse (LPN) confirmed the CRNP should have donned the appropriate Personal Protective Equipment (PPE), gowns and gloves, prior to entering Resident R42's room to provide the assessment and care due to Resident R42 being in EBP for having a chronic stage four (full thickness loss of skin and bone exposed) coccyx pressure ulcer and foley catheter (tubing entering the bladder to drain urine). Observations on 1/06/25, at 12:45 p.m. and 1/07/25, at 12:00 p.m., revealed no PPE available at the doorway or in the hallways for EBP for room [ROOM NUMBER] (resident with a foley catheter and chronic wound), room [ROOM NUMBER] (resident with colostomy-artificial opening from the colon that permits passage of intestinal contents), room [ROOM NUMBER] (resident with foley catheter), 324 (resident with foley catheter). An interview on 1/07/25, at 12:10 p.m. with Nursing Assistant Employee E2 confirmed the facility did not have PPE readily available for staff to utilize for residents that are in EBP. During an interview on 1/07/25, at 2:10 p.m. the Director of Nursing confirmed that employees should be wearing appropriate PPE, such as gloves and gowns, when providing care for residents who are in EBP, and the PPE should be readily available. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395536 Page 12 of 12