Health inspection·August 14, 2025

F 0628 Level of Harm - Potential for minimal harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:Number of residents cited:Findings Include:Review of facility policy, Bed Hold dated 1/4/25, indicated, Upon admission and when a resident is transferred for hospitalization or therapeutic leave, information will be provided concerning our bed-hold policy. When emergency transfers are necessary, the facility will provide the resident or representative with information concerning our bed-hold policy within 24 hours of such transfer.Review of the clinical record indicated Resident R3 was readmitted to the facility on [DATE].Review of Resident R3's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 7/15/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and history of a stroke. Review of Section C: Cognitive Patterns indicated Resident R3 had moderate cognitive impairment.Review of a progress note dated 7/6/25, at 6:50 p.m. indicated, resident c/o (complaining of) abd (abdominal) pain and keeps dozing off glucose 380 daughter at bedside reporting to Nurse that this is not her normal requesting to send her to ER assessment done bowel sounds present times 4 resident had bm (bowel movement) today does have pain with palpation md aware will continue to follow up taken out via ambulance vitals stable see vital sheet.Further review of Resident R3's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R3 or the resident representative upon transfer.Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of Resident R5's MDS dated [DATE], included diagnoses of a hip fracture, high blood pressure, and dementia. Review of Section C: Cognitive Patterns indicated Resident R5 was so cognitively impaired to be unable to complete the assessment interview.Review of a progress note dated 4/17/25, at 2:16 p.m. indicated that Resident R5 had hip and shoulder fractures.Review of a progress note dated 4/17/25, at 2:21 p.m. indicated emergency services were called to transport R5 to the hospital. RFurther review of Resident R5's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident R5 or the resident representative upon transfer.Review of the clinical record indicated Resident R13 was admitted to the facility on [DATE].Review of Resident R13's MDS dated [DATE], included diagnoses of high blood pressure, and muscle weakness. Review of Section C: Cognitive Patterns indicated Resident R89 had moderate cognitive impairment.Review of a progress note dated 6/3/25, at 12:18 p.m. indicated, right 4th and 5th toe blue dusky in color. spoke with [provider] office he wants sent to ER for eval. Husband notified and agreeable. Np [nurse practitioner] aware and agreeable. [Emergency services] called for transport. [hospital] ER called for report.Review of a progress note dated 6/18/2025 1:36 p.m. indicated, Resident sent to ER by wound clinic due to wound infection and temp. resident admitted to [hospital.]Further review of Resident 13's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R13 or the resident representative upon Page 1 of 15 395629 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0628 Level of Harm - Potential for minimal harm Residents Affected - Some transfer for hospitalizations on 6/3/25, and 6/18/25 Review of the clinical record indicated Resident R47 was admitted to the facility on [DATE].Review of Resident R47's MDS dated [DATE], included diagnoses of anemia (too little iron in the body causing fatigue), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), and high blood pressure. Review of Section C: Cognitive Patterns indicated Resident R47 was so cognitively impaired to be unable to complete the assessment interview.Review of a progress note dated 5/5/25, at 5:47 p.m. indicated, Resident fell to floor, right upper leg pain noted, legs aligned, unable to bear weight on RLE (right lower extremity), assisted to bed, [emergency services] notified.Further review of Resident 47's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R47 or the resident representative upon transfer.During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of four residents reviewed for hospitalization.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa Code: 201.29(f)(g) Resident 395629 Page 2 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0636 Level of Harm - Potential for minimal harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Number of residents sampled:Number of residents cited: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 an admission MDS assessment was to be completed no later than 14 days following admission, and annual MDS assessment was to be completed no later than Assessment Reference Date (ARD). Resident R15 had an admission date of 6/13/25, with an interview on 8/14/25, at approximately 10:10 a.m. Registered Nurse Assessment Coordinators (RNAC) Employees E1 and E6 confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for 11 of 20 residents. 28 Pa. Code: 211.5(f) Clinical records. 395629 Page 3 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Potential for minimal harm Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set (MDSperiodic review of resident care needs) assessments were completed within the required time frame for five of 20 residents (Residents R20, R34, R39, R42, and R43).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 quarterly MDS assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD). Resident R20 had a Assessment Coordinators (RNAC) Employees E1 and E6 confirmed that the facility failed to make certain that quarterly MDS assessments were completed in the required time frame for 5 of 20 residents. 28 Pa. Code: 211.5(f) Clinical records. Residents Affected - Some 395629 Page 4 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, staff interviews, and Infection Control Preventionist (ICP) credential review, it was determined that in addition to the role of the Director of Nursing (DON), the DON was also the ICP since 6/18/25.Findings include: During an interview on 8/11/25, at 10:00 a.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) both stated the DON has also been completing the roll as ICP.Review of the DON job description indicated the DON is responsible for the planning, organization, development, and direction of the overall operation of the Nursing Department in accordance with facility policy and procedures, state and federal guidelines, and all other entities as appropriate.Review of the Infection Preventionist job description indicated the ICP is a member of the nursing administration team whose primary functions are to plan, organize, develop, coordinate, and direct the infection control program and its activities in accordance with the facility's policies and procedures, state and federal guidelines, and all other entities as appropriate to ensure an effective infection control program is maintained at all times.During an interview with the Nursing Home Administrator (NHA) on 8/11/25, at 10:00 a.m., the NHA said she was unaware that the DON could not be the ICP and that, currently, there is no back-up ICP to share the functions of the ICP.Pa Code 211.12(b)(c) Nursing services 395629 Page 5 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meetings (third quarter 11/20/24). Findings Include:Review of Quality assurance and Performance Improvement sign in sheets and attendance records for 11/20/24, failed to reveal the Infection Preventionist (IP), and at least three other staff, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems.During an interview on 8/12/25, at 2:20 p.m. the Nursing Home Administrator confirmed that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of four quarterly meeting (third quarter 11/20/24), as required. Residents Affected - Few 395629 Page 6 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

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 observation, review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of five residents reviewed (R13, R55, R96, and R112).Findings include:Review of facility policy Introduction to the Infectious Process reviewed 1/4/25, indicated contact transmission is the most important and frequent means of transmission of infections. Direct contact is described as direct physical transfer between susceptible host and an infected or colonized person such as during bathing, dressing changes, or turning residents. Direct contact transmission can also occur between memorandum QSO-24-08-NH dated 3/20/24, Enhanced Barrier Precautions (EBP) recommendations include the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organisms (MDRO) status. EBP refer to an infection control intervention designed to reduce transmission of MDRO. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. High-contact resident care activities are defined as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care (urinary catheter, feeding tube, tracheostomy/ventilator, wound care (any skin opening requiring a dressing). Review of the clinical record indicated Resident R13 was re-admitted to the facility on [DATE], with diagnoses that included pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure usually over bony prominences) of sacral area (base of the spine), high blood pressure, and depression.Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 6/13/25, indicated the diagnoses remain current.Review of the physician orders revealed the following: On 2/27/25, check feeding tube (soft, flexible, plastic tube that delivers liquid nutrition directly into the stomach or small intestines, bypassing the mouth and esophagus) placement and record residuals every shift On 2/27/25, feeding tube dressing: cleanse with NSS (normal sterile saline), pat dry, cover with drain sponge or dry dressing. On 2/27/25, resident is NPO (nothing by mouth) on continuous tube feeds all meds to be given via feeding tube every shift. On 7/1/25, sacrum wound: leave wound dressing in place. If soiled, change top dressing only. Review of the baseline care plan dated 2/27/25, indicated Resident R13 received tube feeding.Review of the comprehensive care plan failed to indicate interventions for enhanced barrier precautions.Review of the clinical record indicated Resident R55 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, cancer, and depression.Review of the MDS dated [DATE], indicate the diagnoses remain current.Review of the physician orders revealed the following: On 8/19/24, change ileostomy (opening between abdomen and lower small intestines) appliance every three days and as needed. Assess stoma (surgically created opening on the body) and surrounding tissue with every change.Review of the baseline care plan dated 8/20/24, indicated Resident R55 had a urinary catheter (thin, flexible tube inserted into the bladder to drain urine) and a new ostomy (surgical opening that allows waste to pass out of the body).Review of the comprehensive care plan indicated the following: On 8/20/24, staff to follow enhanced barrier precautions, including proper hand washing techniques to minimize microorganism transmission. On 8/30/24, Providers and staff must clean their hands, including before entering and leaving the room. On 8/30/24, Providers and staff must wear gloves and a gown Residents Affected - Many 395629 Page 7 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many for all high-contact resident care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy, ostomy, wound care, any skin opening requiring a dressing.Review of the clinical record indicated Resident R96 was re-admitted to the facility on [DATE], with diagnoses that included pressure ulcer of sacral region, gastrostomy (surgically created opening to place a tube into the stomach), and cystostomy (surgical opening created in the bladder to drain urine).Review of the MDS dated [DATE], revealed the diagnoses remain current.Review of the physician orders revealed the following: On 6/12/24, left and right posterior upper thigh wound care. Cleanse wound with soap and water after removing old dressing. Cover with a border foam dressing On 10/15/24, feeding tube dressing, cleanse with NSS, pat dry, caover with drain sponge or dry dressing every night shift. On 2/12/25, suprapubic catheter, change monthly at urology. On 5/13/25, Sacrum wound care. Cleanse with soap and water, apply collagen to wound. Keep covered at all times.Review of the baseline care plan dated 10/16/24 indicated Resident R96 was receiving tube feedings, an indwelling catheter, and a sacral wound on posterior left thigh.Review of the comprehensive care plan failed to reveal interventions for enhanced barrier precautions.Review of the clinical record indicated Resident R112 was admitted to the facility on [DATE], with diagnoses that included anxiety, carrier or suspected carrier of Methicillin Resistant Staphylococcus Aureus (MRSA - type of bacteria that is resistant to many antibiotics), depression, and anxiety.Review of the physician orders revealed the following: On 8/9/25, foley catheter care every shift with soap and water.Review of the comprehensive care plan dated 8/11/25, indicated the resident has an urinary tract infection MRSA, and an indwelling urinary catheter. It failed to reveal interventions for enhanced barrier precautions.During observations on 8/11/25, between 11:00 a.m. and 12:00 p.m. failed to reveal Resident R13, R55, R96, and R112 were placed in Enhanced Barrier Precautions.During an interview on 8/12/25, at 2:20 p.m. the Director of Nursing confirmed the facility failed to implement infection control measures of enhanced barrier precautions to prevent the potential spread of infection. 395629 Page 8 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for two of twelve months (January 2025, and February 2025).Review of facility policy Antibiotic Stewardship Program reviewed 1/4/25, indicated the purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics to provide the best resident outcomes and to reduce the threat of antibiotic resistance by organisms. Review of the facility's Infection Control surveillance for September 2024 through July 2025, failed to include documentation to indicate that antibiotic monitoring was completed for January 2025 and February 2025.During an interview on 6/11/25, at 2:40 p.m. the Director of Nursing confirmed she was unable to locate the antibiotic monitoring for January 2025 and February 2025. Residents Affected - Many 395629 Page 9 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0941 Level of Harm - Potential for minimal harm Residents Affected - Many Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for facility staff.Findings include: Review of the Facility Assessment most recently reviewed July 2025, listed under the training topics Communication - effective communication for direct care staff. Review of individual training records and the education topics provided to staff on the Annual In-Service and Abuse Training document failed to reveal documentation that training on Effective Communication was provided to staff. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on Effective Communication for facility staff. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395629 Page 10 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0942 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Resident Rights for four of ten staff members (Employees E1, E2, E3, and E4).Findings include: Review of the Facility Assessment most recently reviewed July 2025, listed under the training topics Resident's rights and facility responsibilities. Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have Resident Rights in-service education between 8/11/24, and 8/11/25. Nurse Aide Employee E2 had a hire date of 7/20/15, failed to have Effective Communication in-service education between 7/20/24, and 7/20/25. Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have Effective Communication in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have Effective Communication in-service education between 6/13/24, and 6/13/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on Resident Rights for four of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395629 Page 11 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Findings include: Review of the Facility Assessment most recently reviewed July 2025, listed under the training topics Abuse, Neglect, and Exploitation. Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have Prevention of Abuse and Neglect in-service education between 8/11/24, and 8/11/25. Nurse Aide Employee E2 had a hire date of 7/20/15, failed to have Prevention of Abuse and Neglect in-service education between 7/20/24, and 7/20/25. Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have Prevention of Abuse and Neglect in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have Prevention of Abuse and Neglect in-service education between 6/13/24, and 6/13/25. Licensed Practical Nurse Employee E5 had a hire date of 8/1/16, failed to have Prevention of Abuse and Neglect in-service education between 8/1/24, and 8/1/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on Prevention of Abuse and Neglect for five of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395629 Page 12 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0944 Level of Harm - Potential for minimal harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Findings include: Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have the QAPI Program in-service education between 8/11/24, and 8/11/25. Nurse Aide Employee E2 had a hire date of 7/20/15, failed to have QAPI Program in-service education between 7/20/24, and 7/20/25. Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have QAPI Program in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have QAPI Program in-service education between 6/13/24, and 6/13/25. Licensed Practical Nurse Employee E5 had a hire date of 8/1/16, failed to have QAPI Program in-service education between 8/1/24, and 8/1/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on the QAPI Program for five of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395629 Page 13 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on the Infection Control Program for two of ten staff members (Employees E3 and E4).Findings include: Nurse Aide Employee E3 had a hire date of 8/4/22, failed to have Infection Control Program in-service education between 8/4/24, and 8/4/25. Nurse Aide Employee E4 had a hire date of 6/13/22, failed to have Infection Control Program in-service education between 6/13/24, and 6/13/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on the Infection Control Program for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395629 Page 14 of 15 395629 08/14/2025 MT Macrina Manor 520 West Main Street Uniontown, PA 15401

F 0949 Level of Harm - Potential for minimal harm Residents Affected - Some Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on review of facility documents, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of ten staff members (Employees E1 and E5).Findings include: Registered Nurse Employee E1 had a hire date of 8/11/03, failed to have Behavioral Health in-service education between 8/11/24, and 8/11/25. Licensed Practical Nurse Employee E5 had a hire date of 8/1/16, failed to have Behavioral Health in-service education between 8/1/24, and 8/1/25. During an interview on 8/14/25, at approximately 12:00 p.m. the Director of Nursing confirmed that the facility failed to provide training on Behavioral Health for two of ten staff members. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395629 Page 15 of 15