**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a baseline care plan that included the information necessary to properly care for a resident within 48 hours of admission for two of 24 residents reviewed. (Resident R69) Findings include: Facility policy titled Baseline Care Plan (2024), indicated that This facility will develop an initial person-centered care plan within the first forty-eight (48) hours of admission for every resident. The Baseline Care Plan will provide instructions for care of the resident. Completion and implementation of the Baseline Care Plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among all facility staff members, increase resident safety and safeguard against adverse events that are most likely to occur in the immediate days after admission prior to development of the Comprehensive Care Plan and to ensure the resident and representative are informed of the initial plan for delivery of care and services by receiving a written summary of the Baseline Care Plan or a copty of the Baseline Care Plan. Review of Resident R69's clinical record revealed Resident R69 was admitted to the facility on [DATE] with a diagnosisof aftercare following joint replacement surgery, major depressive disorder, urinary tract infection, and Type 2 diabetes (condition that affects how the body uses sugar as a fuel). Review of Resident R69's clinical record revealed Resident R69 had a care plan initiated September 23, 2024. The baseline care plan only included one focus area, which was resident will transition to long term care after rehab. Resident R69 did not have a completed baseline care plan until September 26, 2024, which is after Resident R69's 48 hours of admission. Review of Resident R315's clinical record revealed Resident R315 was admitted to the facility on [DATE] with a diagnosis of heart failure (condition where the heart cannot pump as well as it should), dysphagia (difficulty swallowing), and hypertension (high blood pressure). Review of Resident R315's clinical record revealed Resident R315 had a care plan initiated October 7, 2024. Resident R315's baseline care plan did not include the minimum healthcare information necessary to properly care for Resident R315 until after 48 hours of Resident R315's admission. Interview on September 17, 2024 at 11:40 a.m with Employee E7, Licensed Practical Nurse, confirmed Resident R69 and Resident R315 did not have a their baseline care plans completed within 48 hours of admission. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with the resident's needs for one of two residents reviewed for nutrition (Resident R52). Findings Include: Review of facility policy dated January 16, 2024, Recording The Weight of Each Resident revealed if a resident shows a 5% weight gain or loss, the Dietitian should be notified. Any resident with a significant weight loss should be included on the 24 hour report for that day. Review of Resident R52's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 13, 2024, revealed Resident R52 had moderate cognitive impairment and had diagnoses of weakness and Cerebral Vascular Accident. Observation of Resident R52 on October 15, 2024, at 11:05 a.m. revealed Resident R52 had bilateral hand tremors. Interview with Resident R52 on October 15, 2024, at 11:05 a.m. Resident R52 reported mealtimes can be difficult because the food falls off the utensil. Continued interview with Resident R52 revealed the resident will get frustrated at mealtimes and ends up not eating. Resident R52 reported history of weight loss. Review of Resident R52's clinical record revealed the resident was readmitted to the facility following a hospitalization on March 7, 2024. Continued review of Resident R52's clinical record revealed the resident was weighed on March 8, 2024, at 168.5 pounds. Review of Resident R52's nutrition assessment dated [DATE], completed by Registered Dietitian, Employee E11, revealed Resident R52 had a fair appetite and was not able to feed self. Resident R52 was noted with meal intakes of 25-50%. Resident R52's nutritional needs were assessed based on intact skin at that time. Recommendations included to provide a 4-ounce supplement (contained 240 calories & 10 grams protein) one time per day to increase PO (by mouth) intake. Continued review of Resident R52's nutrition assessment dated [DATE], revealed the resident's nutrition diagnosis was inadequate PO intake related to diagnoses and advanced age, as evidence by meal consumptions of 25-50%. Review of Resident R52's medication/treatment administration, physician orders, and clinical record revealed no documented evidence the 4-ounce supplement as implemented as recommended by the Registered Dietitian, Employee E11, on March 12, 2024. Review of Resident 52's physician order history revealed a physician order with a start date of March 27, 2024, for a calorie count over 3 days and to send the results to dietary when completed. Review of Resident R52's clinical record revealed no documented evidence the calorie count was completed as ordered. Continued review of Resident R52's clinical record revealed no documented evidence the Registered Dietitian followed-up with the ordered calorie count. Further review of Resident R52's clinical record revealed Resident R52 was noted with discoloration to the left sacrum on March 26, 2024. Resident R52 was subsequently assessed by the Nurse Practitioner, Employee E13, on April 2, 2024, who identified the area on the left sacrum as a stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer). Review of Resident R52's clinical record revealed Resident R52 was assessed by the Nurse Practitioner, Employee E13, again on April 9, 2024.The Nurse Practitioner, Employee E13, revealed the stage 2 pressure ulcer had worsened and was now categorized as an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the would bed is obscured by slough or eschar). Review of Resident R52's clinical record revealed no documented evidence the Registered Dietitian followed-up to reassess the resident's nutrition needs to align with Resident R52's increased calorie and protein needs to promote wound healing. Resident R52 was weighed again on April 4, 2024, at 158.3 pounds which reflected a 10 pound and 6.44% significant weight loss from March 8, 2024. Review of Resident R52's clinical record revealed the Registered Dietitian did not re-assess Resident R52's nutrition status and nutritional needs until April 26, 2024. Interview on October 18, 2024, at 12:36 p.m. with Registered Dietitian, Employee E12, confirmed Resident R52 had a significant weight loss from March 8, 2024, to April 4, 2024, and was not assessed until April 26, 2024. Further interview with the Registered Dietitian, Employee E12, confirmed the supplement was not implemented as recommended from the nutrition assessment on March 12, 2024. The Registered Dietitian, Employee E12, also confirmed there was no follow-up to the calorie count that was ordered by the physician on March 27, 2024. Registered Dietitian, Employee E12, was unable to provide evidence of the results from the calorie count. Continued interview on October 18, 2024, at 12:36 p.m. with Registered Dietitian, Employee E12, confirmed there was no nutrition follow-up to re-assess Resident R52's energy needs when the skin breakdown was identified on April 2, 2024. 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (d)(3) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, review of clinical records, review of facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for two of five residents reviewed for monthly medication review. (Resident R6 and R34). Findings Include: Review of the policy Medication Regimen Review dated June 28, 2019, revealed that the consultant pharmacist performs a comprehensive medication regimen review at least monthly. Findings and recommendations are reported to the Director of Nursing and Attending Physician. Recommendations are acted upon and documented by the facility staff and/or prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Review of Resident R6's medical record revealed that resident was admitted on [DATE], with diagnoses including dementia (general term for a decline in cognitive function). A review of the consultant pharmacist report for Resident R6 on July 21, 2024, included a recommendation to increase Memantine (medication to treat Alzheimer's type dementia) gradually to 10 milligrams (mg) twice a day for an optimal response. A review of Resident R6's physician orders for October 2024, revealed that the resident was still receiving 10 mg of Memantine once a day at bedtime as ordered on April 10, 2024. A review of Resident R6's physician progress notes revealed no review of the July 21, 2024, pharmacy recommendation to gradually increase the dose of memantine to 10 mg twice a day, to include what action, if any, would be taken and the rationale for not taking any action. Interview with the Director of Nursing on October 20, 2024, revealed that there was no documentation available to review related to the recommendations made by the consultant pharmacist or whether they were acknowledged by the physician and implemented or not and why. Review of Resident R34's physician order history and medication administration record revealed the resident was ordered Potassium chloride (mineral supplement used to treat or prevent low amounts of potassium in the blood) from July 6, 2024, through August 2, 2024, when the resident was discharged home. Review of facility documentation dated July 16, 2024, revealed that based on a monthly medication review for Resident R34, the consulting pharmacist recommended to administer Potassium chloride with 4 (ounces) of fluid or food to reduce the risk for esophageal erosion. The consulting pharmacist further specified to add directions to the medication administration record to avoid an error. Review of Resident R34's clinical record revealed no documented evidence the consultant pharmacist's recommendation from July 16, 2024, was addressed or implemented. 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to implement enhanced barrier precautions for eight of eight residents reviewed (Resident R16, R48, R82, R88, R416, R4, R1 ) Findings Include: Review of facility policy dated November 2023 Enhanced Barrier Precautions revealed it is the policy of the facility to use enhanced barrier precautions with residents who are at risk for acquisition and colonization of multidrug resistant organisms (MDRO's). The use of Enhanced Barrier Precautions is indicated during high contact resident care activities for residents with chronic wounds and/or indwelling devices regardless of MDRO colonization. A review of Resident R16's clinical record revealed the resident was admitted to the facility on [DATE], and had a diagnosis of neuromuscular dysfunction of the bladder (neurogenic bladder, the relationship between the nervous system and bladder function is disrupted by injury or disease). Further review of Resident R16's clinical record revealed a physician order for a foley catheter (sterile tube that is inserted into the bladder to drain urine). Observation of Resident R16 in room [ROOM NUMBER]D on October 15, 2024, revealed resident resting in bed with eyes closed and a urine collection bag was hanging on the side of the bed. Further observation revealed no signage on the resident's door to indicate that the resident was on enhanced barrier precautions. Review of Resident R48's clinical record revealed a physician order dated March 27, 2024, for a coude catheter (type of urinary catheter to drain urine). Further review of Resident R48's clinical record including physician orders, progress notes, and comprehensive care plan revealed no documented evidence the resident was on enhanced barrier precautions. Review of Resident R82's clinical record revealed a physician order dated April 15, 2024, for a suprapubic catheter (a type of urinary catheter that is inserted into the bladder through an incision in the belly to drain urine). Further review of Resident R82's clinical record including physician orders, progress notes, and comprehensive care plan revealed no documented evidence the resident was on enhanced barrier precautions. Review of Resident R88's clinical record revealed a physician order dated May 10, 2024, for a suprapubic catheter. Further review of Resident R88's clinical record including physician orders, progress notes, and comprehensive care plan revealed no documented evidence the resident was on enhanced barrier precautions. Review of Resident R416's clinical record revealed a physician order dated October 2, 2024, for a foley catheter. Further review of Resident R416's clinical record including physician orders, progress notes, and comprehensive care plan revealed no documented evidence the resident was on enhanced barrier precautions. Observations of Resident R416 in room [ROOM NUMBER]D on October 15, 2024, at 10:26 a.m. revealed no signage on the resident's door and/or in the resident's room to indicate that the resident was on enhanced barrier precautions. Interview on October 16, 2024, at 11:45 a.m. with Registered Nurse, Employee E8, confirmed Resident R82, R88, and R48 had catheters. Further interview with Registered Nurse, Employee E8, revealed no residents were on enhanced barrier precautions. Follow-up observations on October 16, 2024, at 11:45 a.m. revealed no signage on the resident doors and/or in the resident rooms to indicate that Residents R82, R88, and R48 were on enhanced barrier precautions. Interview on October 17, 2024, at 11:11 a.m. with Infection Preventionist, Employee E9, confirmed enhanced barrier precautions were not in place. Review of Resident R4's clinical record revealed Resident R4 was admitted to the facility on [DATE] with the diagnoses of unspecified dementia; depression; essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris; osteoarthritis of the knees; repeated falls; obstructive and reflux uropathy; and difficulty in walking. Further review Resident R4's October 2024 physican orders revealed an order for Coude Catheter 20 French/ 30 ccwater. Catheter care every shift. Cleanse area with soap and water every shift. Observation of Resident R4's room did not reveal enhanced barrier precaution signage and there was no evidence of PPE (personal protective equipment) available outside room [ROOM NUMBER]. Interview on October 16, 2024 at 11:30 a.m. with Employee E5 confirmed that staff does not wear a gown while performing urinary catheter care. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] with the diagnoses of heart disease of native coronary artery without angina pectoris. Observation of treatment to Resident's R1 sacral and heel wounds on October 17, 2024 at 10:40 a.m. with Wound nurse, Employee E15, and Licensed nurse, Employee E5, revealed hand sanitizer and and gloving were maintained. There was no transmission based signage or PPE (personal protective equipment) supply noted outside of room [ROOM NUMBER]. Interview on October 17, 2024 at 11:00 a.m. with Employee E15 confirmed there was no transmission based precaution signage or PPE available during wound care for Resident R1. The facility did not implement enhanced barrier precautions related to catheter care and wound care. 28 Pa. Code 211.10( d) Resident care policies 28 Pa. Code 211.112(d)(1) Nursing services

Based on review of policies, information provided by the facility, and clinical records review, and staff interviews, it was determined that the facility failed to ensure that staff report an alleged violation involving an injury of unknown origin within the required timeframe for one of 27 residents reviewed (Resident 21). Findings include: A nursing note for Resident 21, dated December 7, 2023, revealed that the resident was observed by the nursing assistant with bluish discoloration above left eyebrow ridge. It measured 1.5 centimeter (cm) x 2.5 cm, and the area was slightly elevated. Review of facility investigation dated December 7, 2023, at 4:30 p.m., revealed that the nursing assistant reported bruise to left eyebrow ridge measured 1. 5cm x 2. 5cm. The bruise was dark purple in color. Resident stated he was punched in the face by the person that took me to the get my hair cut. Further review of investigation revealed a statement by Licensed Practical Nurse (LPN), Employee E14, indicated she observe the bruise before lunch time when she was assisting nurse aide, Employee E15, to transfer Resident R21. Employee E14 asked Employee E15 about the bruise, what it was, Employee E15 did not know what it was. The statement did not include any evidence that Licensed Practical Nurse(LPN), Employee E14 reported this allegation to administrator or to the supervisor. Review of a statement by nurse aide, Employee E16, dated December 7, 2023, revealed that she observed a small spot on the corner of his eye when she went into his room to ask him if he wanted a haircut. Review of a statement written by Director of Nursing (DON) dated December 8, 2023, revealed that she noticed a bruise to lateral side of his left eye of Resident R21. She asked Resident R21 what happened, and his response was I was punched, Resident was unable to identify the person but stated It was the little one that took me to get my haircut. Resident also stated, she didn't like something and just punched me. Resident R21 told the DON Please don't tell her I am afraid of her. When asked why resident replied, because she is always rough with me but now I am afraid she's gonna come back and kill me. Review of a corrective action document for nurse aide, Employee E15, dated December 12, 2023, revealed that on December 7, 2023, LPN, Employee E14 noticed a red area on the side of the resident's left eye and questioned Employee E15 who provided care to him. Employee E15 stated nothing unusual happened during her shift. Employee E15 was place on investigatory suspension. Continued review of the document revealed that on December 12, 2023, Employee E15 denied anything occurred on her shift. When questioned about LPN's conversation about the resident's area of concern with his left eye she denied anything occurred and did not report this incident. Review of a corrective action document for nurse aide, Employee E16, dated December 14, 2023, revealed that Employee E16 noticed a red area to the side of Resident R21's left eye. Employee E16 failed to report the finding to any nurse or supervisor. It was the responsibility of all staff to report any concerns (inclusive of but limited to falls, injuries, cuts, and/or bruises) to the assigned charge nurse and/or the nursing supervisor. Review of a corrective action document for LPN, Employee E14, dated December 14, 2023, revealed that Employee E14 noticed a red area to the side of Resident R21's left eye. Employee E14 failed to report the finding to any nurse or supervisor. Review of a timeline of the facility camera revealed that LPN, Employee E14 and nurse aide, E15 was in resident's room at 12:08 p.m., (Employee E14 first observed that bruise and questioned Employee E15). At 12:11 p.m., Nurse aide, Employee E16 went into resident's room, she observed the bruise. At 12:17 p.m. resident was taken to the beauty salon. At 2:52 p.m. Nurse aide, Employee E15 left the unit after her shift. At 5:05 nursing assistant, Employee E17, called the nurse to resident's room who called the supervisor at 5:08 p.m., Continued review of facility investigation dated December 7, 2023, revealed that Employee E14, E15, and E16 failed to report Resident R21's alleged injury of unknown origin to the administrator or supervisor as required and failed to initiate an investigation in a timely manner. Interview with the Nursing Home Administrator (NHA) on December 29, 2023, at 11:00 a.m. confirmed that Employee E14, E15, and E16 failed to report Resident R21's bruise to the left eye area in a timely manner. NHA stated Employee E14, E15, and E16 did not report the injury and left for their shift. It was reported by Employee E17, subsequently facility investigation was initiated. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included continuous oxygen administration for one of 33 residents reviewed (R41) Findings include: Review of Resident R41's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnoses that included Heart Failure (a condition that develops when the heart doesn't pump enough blood for the body's needs. This can happen if the heart can't fill up with enough blood. It can also happen when the heart is too weak to pump properly), Atrial Fibrillation (an irregular and often very rapid heart rhythm; it can lead to blood clots in the heart, increases the risk of stroke, heart failure and other heart-related complications), Acute Kidney Failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days, it causes a build-up of waste products in the blood and makes it hard for the kidneys to keep the right balance of fluid in the body). Review of physician order for Resident R41, dated November 25, 2023, indicated an order to administer Oxygen continuously at 2 Liters/minute, via nasal canula/mask, every shift. Review of the care plan for Resident R41, revealed that there were no focus, interventions, and outcomes (goals) care- planned for oxygen administration. On December 29, 2023, at 10:27 a.m., interview with the Director of Nursing confirmed the above findings. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and clinical records review, it was determined that the facility failed to ensure that that physician orders were followed related to urinary catheter size for one of one residents reviewed with a urinary catheter. (Resident R42) Findings include: Review of Resident R42's clinical record revealed that Resident R42 was admitted to the facility on [DATE] with the diagnoses of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment; symptoms include forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning), Major Depressive Disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety Disorder and Malignant Neoplasm of Right Female Breast (The term malignant means the tumor is cancerous and is likely to spread (metastasize) beyond its point of origin). Review of physician order dated December 1, 2023, for Resident R42, indicated an order for suprapubic catheter size 18 French/10cc balloon. On December 29, 2023, at 10:29 a.m., reviewed the suprapubic catheter of Resident R42, in the presence of Licensed nurse, Employee E13, and observation completed at the time revealed that Resident R42 had suprapubic catheter size 16 French, with the balloon size not clear. 28 Pa. Code 211.12(d)(1) Nursing services

Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater. Findings include: The facility incurred a medication error rate of 6.25%. Review of R34's physician order revealed an order dated November 1, 2021, to administer Amlodipine Besylate 5 milligrams, give one tablet orally in the morning, for hypertension; hold for systolic blood pressure (SBP) less than 100. (Systolic Blood Pressure indicates how much pressure the blood is exerting against the artery walls when the heart contracts). (Hypertension is high blood pressure; if an individual has high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart has to work harder to pump blood). On December 28, 2023, at 9:38 a.m., observed that Employee E13, a Licensed Nurse, administered Amlodipine Besylate 5 milligrams, one tablet, orally to Resident R34. Employee E13 did not check the blood pressure of Resident R34, prior to or at the time of administration of Amlodipine Besylate 5 Mg tablet. Review of Resident R34's physician order revealed an order dated November 1, 2021, to administer Losartan 100 mg tablet, give one tablet orally, in the morning, related to Essential (Primary) Hypertension, hold for Systolic Blood Pressure (SBP) less than 100. On December 28, 2023, at 09:38 a.m., observed that Licensed nurse, Employee E13, administered Losartan 100 milligrams, one tablet, orally to Resident R34. Employee E13 did not check the blood pressure of Resident R34, prior to or at the time of administration of Losartan 100 mg. At the time of the observation, interviewed with Employee E13, confirmed the findings. Pa Code:211.12(d)(1)(2)(5) Nursing Services.

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete one of 30 residents reviewed (Resident R77). Findings Include: Review of Resident R77's dietary progress note dated December 28, 2023, revealed that the resident was trending weight loss for past several months. The dietician was monitoring weekly weights, labs, meal intake and tolerance. Review of Resident R77's November 2023 meal intake documentation revealed that on 19 days only one meal intake was documented. December 2023's meal intake documentation revealed that for 12 days only one meal was documented. Continued review of December 2023's meal intake documentation on December 5, 9 and 15, 2023 only two meals were documented. Interview with the Registered Dietician on January 2, 2023, at 12:00 p.m. stated the resident was not on weekly weight when the dietician completed the documentation on December 28, 2023. Dietician also confirmed that the meal intake documentation was not consistently completed for Resident R77. 28 Pa. Code 211.5(f)(ii) Medical records

Based on observation, clinical record review, and review of facility documentation, it was determined that the facility failed to maintain proper infection control measures for COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) in one of two nursing units (second floor). Findings include: A review of the facility documentation dated December 28, 2023, revealed 8 residents were residing in the designated COVID-19 rooms on the second floor. Interview with the Nursing Home Administrator and Director of Nursing on December 27, 2023, at 9:30 a.m. revealed that the facility was having a COVID outbreak, 8 residents are located on the second floor. The required Protective Personal Equipment (PPE) for the COVID rooms as required by facilities policy Transmission-Based Isolation Precautions that PPE to be donned upon entrance to the resident room includes goggle or face shield, facemask N95, disposable gowns, and gloves. PPE will be doffed prior to exit of the room and discarded in isolation bins placed inside of resident's doorway . Every staff, and/or visitor going into COVID room must put on all PPE when going into the resident's room who are diagnosed with COVID. Observation conducted on December 28, 2023, between 10:35 a.m. to 10:40 a.m. on the second floor, revealed Housekeepers, Employee E8 and E9 were going in and out of the COVID rooms without appropriate PPE such as mask N95, and face shield. Also, Employee E9 was observed exiting COVID room without appropriately doffing and putting dirty gown in a clean cart with other clean gowns. When Housekeepers, Employee E8 and E9 were interviewed, they both reported that they were train on PPE to be put on upon entrance and taken prior to exit COVID rooms. On December 28, 2023, at 11:00 a.m. interview with Director of Nursing, Employee E3 and Assistant Director of Nursing, Employee E10, confirmed that all staff and visitor going into COVID rooms must put on all PPE when going into resident's room who are diagnosed with COVID and doffed when exiting by infection control policies and procedures. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 PA. Code 211.12(d)(5) Nursing services