**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, observation, and staff interviews, it was determined that the facility failed to establish, implement and maintain an effective infection control program related to enhanced barrier precaution, relating to staff education, proper signage and available personal protective equipment (PPE) for three of three reviewed. (Resident 3, Resident R10, and Resident 129) Finding includes: Review of facility policy titled Enhanced Barrier Precautions revealed that enhanced barrier is an approach to the use of personal protective equipment (PPE) to reduce transmission of Multi Drug Organisms between residents in skilled nursing facilities. Enhanced barrier precautions (EBP) expand the use of gowns and gloves beyond standard precautions. The strategy calls for healthcare personal to wear specific (PPE) during high contact resident t care activities for resident known to be infected or colonized with an MDRO as well as those with increased risk of MDRO, which includes any resident with a wound or indwelling medical device (e.g., central line, urinary catheter, feeding tube, tracheostomy, ventilator) Example of contact care activities include: dressing, bathing, and provide hygiene, changing linens, changing briefs, device care and wound care. Review of Center for Disease Control and Prevention (CDC) policy titled Enhanced Barrier Precautions in Skilled Nursing Facilities dated November 15, 2025, revealed the focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves and make PPE, including gowns and gloves, available immediately outside of the resident room. Further review of CDC policy titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) revealed Enhanced barrier precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. An effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) o For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves Make PPE, including gowns and gloves, available immediately outside of the resident room Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room) Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education Provide education to residents and visitors Observation conducted on February 18, 19, 20, and 21, 2025, revealed three residents' doors with signage on the door consisting of instructions that all see the nurse before entering no indication of precaution and no personal protective equipment (PPE) readily available at point of care were viewed. Review of facility documentation matrix implied that three residents were assessed to be requiring enhanced barrier precaution due to indwelling device and wounds. Review of Resident R10's minimum data set (MDS-federal mandated process for clinical assessment of all residents) dated January 20, 2025 revealed that Resident R10 was admitted into the facility on January 13, 2025 with diagnosis' including benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty) and obstructive uropathy (a urinary tract disorder that occurs due to obstructive urinary flow) and requiring the use of an indwelling catheter. Review of Resident R10's physician order revealed an order for enhanced barrier precaution dated February 19, 2025, one month after being admitted with a suprapubic urinary catheter. Review of Resident R3's quarterly Minimum Data Set, dated [DATE], revealed that Resident R3 was admitted into the facility on October 4, 2024 with two pressure ulcers (areas of damaged skin and soft tissue injuries). Review of Resident R129's MDS quarterly Minimum Data Set, dated [DATE], revealed that Resident R129 was admitted into the facility on February 10, 2025, with a surgical wound. Review of Resident R129's physician order revealed no order for enhanced barrier precaution. Interview with Licensed nurse, infection control preventionist, Employee E 6 on February 19, 2025, at 1:03 p.m. revealed that it is not facility policy that PPE is required during contact such as physical therapy or any contact other than wound care or indwelling device. Employee E6 stated that (PPE) is not required if wounds are covered. Furthermore, Employee E6 stated that is respectful of resident privacy not to place signage on the door that indicated the resident is on any precaution and (PPE) can be obtained at the nurse's station. Interview with Licensed nurse Employee E10 on February 21, 2025, at 8:50 a.m. revealed that this employee has not been educated on enhanced barrier precautions, is unaware of the precaution and what is required. Interview with Licensed nurse, Employee E 11 on February 21, 2025, at 09:00 a.m. revealed that this employee has not been educated on enhanced barrier precautions, did not have any knowledge regarding the precaution and why it is implemented, and believes the posted sign on specific residents door to see the nurse before enter were indicated those residents were receiving hospice program and may not want to be disturbed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.12(d)(5) Nursing Services

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner for one of 12 residents reviewed (Resident R8). Findings include: Review of Resident R8's clinical record revealed that the resident was transferred to the hospital on September 7, 2023, due to fever. Further review of Resident R8's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to Resident R8 and their representative(s). Interview with the facility Administrator, Employee E1, on April 24, 2024, at 9:43 a.m. confirmed that Resident R8 and their representative were not notified in writing of the reasons for the transfer, and in a language and manner they understood. Further interview confirmed there was no system in place regarding written notice before discharge. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on review of the clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error related to the receiving wrong medication which was prescribed for another resident for one of 4 residents reviewed for medication administration (Resident R9). Findings include: Review of FDA (Food and Drug Administration) guidelines for Morphine sulfate revealed that Morphine sulfate is an opioid agonist indicated for the relief of moderate to severe acute and chronic pain where an opioid analgesic is appropriate. (1) Morphine sulfate 100 mg per 5 mL (20 mg/mL) solution is indicated for the relief of moderate to severe acute and chronic pain in opioid-tolerant patients. WARNINGS AND PRECAUTIONS Risk of Medication Errors: Use caution when prescribing, dispensing, and administering to avoid dosing errors due to confusion between different concentrations and between mg and mL, which could result in accidental overdose and death. (5.1) Respiratory depression: Increased risk in elderly, debilitated patients, those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction. (5.2) Controlled substance: Morphine sulfate is a Schedule II controlled substance with an abuse liability similar to other opioids. (5.3) CNS effects: Additive CNS depressive effects when used in conjunction with alcohol, other opioids, or illicit drugs. Review of Physician orders for Resident R9 for April 2024 revealed no evidence that the resident had a physician order for morphine sulfate. Review of a facility investigation dated April 4, 2024, revealed that the charge nurse administered Morphine Sulfate (This medication is used to help relieve moderate to severe pain. Morphine belongs to a class of drugs known as opioid analgesics) 0.25 milligrams to Resident R1 by error. Nurse recognized error when she signed out the medication. Interview with Resident R9 on April 22, 2024, at 11:00 a.m. stated she received the wrong medication approximately 2 weeks ago. Resident stated she was sleeping and during her sleep she was awaken by a nurse by placing something like a liquid in her mouth. Resident stated she was asleep, and the nurse did not ask her anything to identify her. Interview with Director of Nursing on April 24, 2024, at 2:38 p.m. stated nurse did not follow appropriate practice of medication administration. Nurse did not identify the right resident/patient before she administered the medication which resulted in Resident R9 receiving wrong narcotic pain medication which could potentially cause serious side effects. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on observations, interviews with facility staff, review of clinical records and facility documentation, it was determined that the facility failed to ensure that two bruises of unknown origin were reported to the State Survey Agency for 1 out of 12 residents reviewed (Resident R15). Findings include: Review of the facility's policy, Abuse, with an effective date of January 1, 2018 indicated that all incidents of bruising, skin tears or any other abnormality shall be reported to the nurse and an event report completed. The policy also stated that the Director of Nursing (DON) will conduct an investigation on all events deemed to be suspicious or unexplained. If abuse is suspected, the procedure for investigating/reporting abuse shall be followed. Review of the facility policy, Bruises of Unknown Origin, with an effective date of January 1, 2018, the policy indicated that upon identification of a new bruise, the following information should be included in the nurses documentation: date and time of the discovery, size, color and appearance of the bruise, and any potential witnesses or circumstances surrounding the discovery of the bruises. Review of the diagnosis list for Resident R15 provided by the facility included the following: hypertension (high blood pressure); dementia (the loss of cognitive functions such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities); and dysphagia (difficulty swallowing). Review of Resident R15 Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) indicated that the resident was cognitively impaired. Review of nursing note dated August 21, 2022, a 11:59 p.m. indicated that while providing care to the resident during the 3:00 p.m. through the 11:00 p.m. nursing shift, a nursing assistant (Employee E7) reported to licensed nursing staff (Employee E8) that a bruise on the resident's right forearm was found. Continued review of the nursing note indicates that when the Employee E8 went to assess the resident after being notified by the nursing assistant, she indicated that the resident had a large dark bruised area on her forearm. Review of the facility's investigation indicated that staff report resident with some behaviors that she move haphazardly and my [sic] have caused bruising. Continued review of the investigation did not show evidence of what staff reported this and when this behavior was observed. Review of resident's nursing notes provided by the facility from August 1, 2022, through August 21, 2022, did not show evidence of documentation of any events documented by nursing staff that could be related to the bruise (e.g. aggressiveness, combative with care) that may have occurred during this time period within which the resident's bruise was found. Review of a nursing note dated October 24, 2022 at 1:42 p.m. indicated that Resident R15 was noted to have a bruise to her right lower arm that was purple in color. Information reviewed from the facility indicated that the resident's nursing assistant (Employee E9) noticed the bruise to the arm while providing care to the resident and reported it to the nurse (Employee E10). Review of the facility's investigation indicated that staff report patient as striking out during care. Continued review of the investigation did not show evidence of what staff reported this and when this behavior was observed. Review of the resident's nursing notes from October 1, 2022-October 24, 2022 did not show evidence of documentation of any events documented by nursing staff that could be related to the bruise (e.g. aggressiveness, combative with care) that may have occurred during this time period in which the resident's bruise was found. Review of information in the State Survey agency system included no evidence that the facility reported the two referenced bruises of unknown origin to ruled physical abuse. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.14(a) Responsibility of licensee

Based on interviews, the review of clinical records and the review of facility documentation, it was determined that the facility failed to ensure that a complete and through investigation was completed to rule out abuse for two bruises of unknown origin for 1 out of 12 residents reviewed (Resident R15). Findings include: Review of the facility's policy, Abuse, with an effective date of January 1, 2018 indicated that all incidents of bruising, skin tears or any other abnormality shall be reported to the nurse and an event report completed. The policy also stated that the Director of Nursing (DON) will conduct an investigation on all events deemed to be suspicious or unexplained. If abuse is suspected, the procedure for investigating/reporting abuse shall be followed. Review of the facility policy, Bruises of Unknown Origin, with an effective date of January 1, 2018, the policy indicated that upon identification of a new bruise, the following information should be included in the nurses documentation: date and time of the discovery, size, color and appearance of the bruise, and any potential witnesses or circumstances surrounding the discovery of the bruises. Review of the diagnosis list for Resident R15 provided by the facility included the following: hypertension (high blood pressure); dementia (the loss of cognitive functions such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities); and dysphagia (difficulty swallowing). Review of Resident R15 Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) indicated that the resident was cognitively impaired. Review of nursing note dated August 21, 2022, a 11:59 p.m. indicated that while providing care to the resident during the 3:00 p.m. through the 11:00 p.m. nursing shift, a nursing assistant (Employee E7) reported to licensed nursing staff (Employee E8) that a bruise on the resident's right forearm was found. Continued review of the nursing note indicates that when the Employee E8 went to assess the resident after being notified by the nursing assistant, she indicated that the resident had a large dark bruised area on her forearm. Review of the facility's investigation indicated that staff report resident with some behaviors that she move haphazardly and my [sic] have caused bruising. Continued review of the investigation did not show evidence of what staff reported this and when this behavior was observed. Review of resident's nursing notes provided by the facility from August 1, 2022, through August 21, 2022, did not show evidence of documentation of any events documented by nursing staff that could be related to the bruise (e.g. aggressiveness, combative with care) that may have occurred during this time period within which the resident's bruise was found. Review of facility documentation regarding the reported bruise provided no evidence of documentation that the facility conducted an interview with Employee E7 who was assigned to the resident during the noted shift after she reported the bruises. In addition, review of facility documentation also did not show evidence of any interviews with staff on previous shifts (e.g., nurses, nursing assistants, activities staff) that may have witnessed something, observed something, or overheard something, or know of something that would have provided insight/information as to how Resident R15 sustained a bruise on the above noted area to ensure that abuse could be ruled out for the bruise of unknown. Review of a nursing note dated October 24, 2022 at 1:42 p.m. indicated that Resident R15 was noted to have a bruise to her right lower arm that was purple in color. Information reviewed from the facility indicated that the resident's nursing assistant (Employee E9) noticed the bruise to the arm while providing care to the resident and reported it to the nurse (Employee E10). Review of the facility's investigation indicated that staff report patient as striking out during care. Continued review of the investigation did not show evidence of what staff reported this and when this behavior was observed. Review of the resident's nursing notes from October 1, 2022-October 24, 2022 did not show evidence of documentation of any events documented by nursing staff that could be related to the bruise (e.g. aggressiveness, combative with care) that may have occurred during this time period in which the resident's bruise was found. Review of facility documentation regarding the reported bruise provided no evidence of documentation of any interviews with staff on previous shifts (e.g., nurses, nursing assistants, activities staff) that may have witnessed something, observed something, or overheard something, or know of something that would have provided insight/information as to how Resident R15 sustained a bruise on the above noted area to ensure that abuse could be ruled out for the bruise of unknown. During an interview with the Director of Nursing on July 20, 2023, at 1:02 p.m. it was confirmed that there were no additional information/interviews related to the two referenced incidents regarding the resident sustaining two bruises of unknown origin that were discovered on August 21, 2022 and October 24, 2022. 28 Pa. Code 201.14(a)(e) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies

Based on staff interviews, and the review of clinical records, it was determined that the facility failed to ensure that one person who expressed suicidal ideation was assessed and monitored after both occurrences for 1 out 12 residents reviewed (Resident R19). Findings include: Review of the facility's policy, Behavioral Health, with an effective dates of January 1, 2018 indicated that the interdisciplinary team will put appropriate interventions in place to reduce the risk of adverse outcomes related to behavioral health among residents. The policy also indicated that for residents with identified behavioral health issues or those who are deemed at risk of adverse outcomes related to behavioral health, the care plan will be updated to identify appropriate interventions. Continued review of the policy indicated that residents identified at risk of self-harm shall be provided with access to counseling, therapy, or other appropriate mental health interventions, and that all incidents, assessments, interventions, and follow up actions shall be thoroughly documented in the resident's record, ensuring accuracy and consistency. Review of Resident R19's diagnosis provided by the facility included the following: muscle weakness; dementia; sleep apnea; respiratory failure; and pain in left wrist. Review of Resident R19's Quarterly Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) indicated that the resident alert and oriented. Review of a nursing note dated April 5, 2023, at 11:38 a.m. written by Employee E4 indicated that Resident R19 was refusing to get out of bed and take a shower. Continued review of the note indicated that resident reported that she had pain all over and that she just wants to die and stated, why don't you just shoot me. Continued review of the nursing documentation included no evidence in the resident's clinical record that the facility supported the resident's above referenced behavior heath need by not providing appropriate treatment, care and services to the resident. There was no documentation that the facility implemented any measures to ensure the safety of the resident, conducted an assessment or monitor the resident after the resident verbalized statements of self-harm. Review of the nursing note on April 7, 2023 at 4:33 p.m. written by a therapeutic staff member (Employee E11) indicated that resident reported to the employee during her activity session, the resident stated during their session, If I could kill myself I would. The note also indicated that the resident continued to make comments about how she wasn't able to walk, and that her whole body was in pain. Continued review of the nursing documentation included no evidence in the resident's clinical record that nursing staff documented knowledge of the knowing about the comments regarding self-harm that she verbalized to Employee E11, no documentation that the physician was notified regarding resident's statements of self-harm on April 7, 2023 and no evidence that the facility supported the resident's above referenced behavior heath need by providing appropriate treatment, care and services to the resident. Review of Resident R19's psychiatric consult, Psychiatric Evaluation and Management Form, documented that the resident was seen by the psychiatrist on April 17, 2023 regarding her statements of self-harm that were made 10-11 days prior. Review of the resident's current person-centered plan of care did show evidence that a plan of care was developed for resident's statements of self-harm, to ensure that individualized approaches to care are provided to the residents, and to also ensure that staff is understanding, preventing, relieving, and/or accommodating Resident R19's behavioral health needs. During an interview with the Director of Nursing (DON) on July 20, 2023, at 9:21 a.m. regarding the above referenced events related to the resident's statements related to self-harm, it was confirmed that no information could be produced to show evidence that the resident was properly assessed, monitored, and had interventions in place to ensure resident safety. It was also confirmed during this time that the resident's person-centered plan of care did not include a plan of care for the resident's behavioral health needs. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

Based on a review of facility documents, observations, and interviews with staff, it was determined that the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for two units (Care Base One and Care Base Two). Findings include: Review of the facility policy on Controlled Substance storage with an effective date of January 1, 2019, revealed that under section Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. Under section Procedure #D. A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV. Review of facility Narcotic Reconciliation Record (a form where in-coming and the outgoing nurses sign for accountability of the controlled medications in their respective narcotic boxes) for Unit Care Base Two conducted on July 19, 2023, at 9:30 a.m. with licensed nurse Employee E3 revealed that the shift-to-shift accountability had missing signature on July 19, 2023, for the 11 to 7 shift. Further review of the Narcotic Reconciliation record conducted withLicensed staff, Employee E3 revealed that Narcotic Reconciliation only accounted for the count of the controlled substances present at the time of the count but did not account for the individual controlled substance dispensed by the pharmacy. Interview with licensed nurse, Employee E3 conducted at the time of the observation revealed that at the beginning of her shift, she would count the narcotics in the narcotic box located in the medication cart together with the outgoing nurse. Further interview with Licensed nurse, Employee E3 confirmed that there was no list of the current controlled medications that should be present in the narcotic box that needed to be accounted for. Further, Employee E3 revealed that the in-coming and out-going licensed nurses were signing for the controlled substances present in the narcotic box and their corresponding narcotic count sheets in the narcotic binder at the time of the count. Further, Employee E3 confirmed that if an entire blister pack of controlled substance and its corresponding Narcotic count sheet was missing, there was no system in place to account for that missing set of controlled substance and that she would not know that it was missing until the time that the controlled medication has to be administered because there was no list of all the current controlled medications that she can reference during the count. Interview with Director of Nursing, Employee E2 conducted on July 19 20, 2023, at 10:02 a.m. revealed that she will get a running list from pharmacy and use it when nurses are doing narcotic counts between shifts. Review of facility Narcotic Reconciliation Record (a form where in-coming and the outgoing nurses sign for accountability of the controlled medications in their respective narcotic boxes) for Unit Care Base One conducted on July 19, 2023, at 10:31 a.m. with licensed nurse Employee E4 revealed that the shift-to-shift accountability had missing signature on July 19, 2023, for the 11 to 7 shift. Further review of the Narcotic Reconciliation record conducted with Employee E4 revealed that Narcotic Reconciliation only accounted for the count of the controlled substances present at the time of the count but did not account for the individual controlled substance dispensed by the pharmacy. Interview with Licensed nurse, Employee E4 conducted at the time of the observation revealed that at the beginning of her shift, she would count the narcotics in the narcotic box located in the medication cart together with the outgoing nurse. Further interview with Licensed nurse, Employee E4 confirmed that there was no list of the current controlled medications that should be present in the narcotic box that needed to be accounted for. Further, Employee E4 revealed that the in-coming and out-going licensed nurses were signing for the controlled substances present in the narcotic box and their corresponding narcotic count sheets in the narcotic binder at the time of the count. Further, Employee E4 confirmed that if an entire blister pack of controlled substance and its corresponding Narcotic count sheet was missing, there was no system in place to account for that missing set of controlled substance and that she would not know that it was missing until the time that the controlled medication has to be administered because there was no list of all the current controlled medications that she can reference during the count. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, interview with staff and review of policies and procedures, it was determined that the facility failed to develop and implement written standards, policies, and procedures to ensure that positive results of Legionella (Bacteria that causes disease found in contaminated water) culture test the facility's water system is reported to the Infection Control Preventionist or to the designated person, who is responsible for implementing infection control interventions. Findings include: Review of the facility policy and procedure Legionella Surveillance dated March 7, 2016 revealed that under section Policy: this policy reviews the surveillance steps used should Legionella be diagnosed at [NAME]. Inder section Background: Legionnaire's disease is a very serious type of pneumonia caused by a bacteria called Legionella. Under section Surveillance: If a single case of legionnaire's disease is confirmed, the following measure will take place; Bullet #3: Per water management policy- the area that test positive will be removed until from service until cleaned by our contracted water management company. Further review of the facility policy on Legionella Surveillance revealed that the policy did not indicate when and to whom a positive Legionella culture test of the facility's water system is reported to. Review of the facility's governing guideline for its Water Management Program for building water systems revealed that guideline did not indicate when and to whom a positive Legionella culture test of the facility's water system is reported to. Review of facility's water testing record conducted on July 20, 2023, revealed that the water sample from the oxygen room was obtained on June 29, 2023, and test result completed on July 13, 2023, and authorized on July 14, 2023. Further review of the water testing record revealed that test result was 1 CFU (colony forming unit)/milliliter. Interview with the Director of Maintenance, Employee E6 conducted on July 20, 2023, at 9:30 a.m. confirmed that the test result for the water testing in the oxygen room tested positive for legionella. Further, Employee E6 revealed that he informed the infection preventionist, Employee E5 of the water testing result the morning of July 20, 2023, when the test result of the facility's most recent water testing was requested by the surveyor. Further interview with Employee E6 revealed that he did not know that he has to inform Employee E5. Further, Employee E 6 confirmed that the facility Water Management Program did not indicate who needed to be informed of a positive legionella culture test. Interview with the infection preventionist, Employee E5 conducted on July 20, 2023, at 9:48 a.m. confirmed that she didn't know about the positive result until this morning, July 20, 2023. Further interview with infection preventionist, Employee E5 revealed that the facility did not have a policy on when and whom to report a positive Legionella culture and that there was no policy on what to do when a positive result for Legionella is detected in the facility water system. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management