Health inspection·October 11, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of facility policies, review of the Pennsylvania Department of Health 2023-PAHAN-694-05-11-UPD, Update: Interim Infection Prevention and Control Recommendations for COVID-19 in Healthcare Settings and staff interviews, it was determined that the facility failed to follow infection control measures to prevent possible cross contamination on one of two units (2-West). Residents Affected - Some Findings include: Review of the Pennsylvania Department of Health 2023-PAHAN-694-05-11-UPD, Update: Interim Infection Prevention and Control Recommendations for COVID-19 in Healthcare Settings states As SARS-COV-2 transmission in the community increases, the potential for encountering asymptomatic or pre-symptomatic patients with SARS-COV-2 infection also likely increases. In these circumstances, healthcare facilities should consider implementing broader use of respirators and eye protection by Healthcare Provider (HCP) during patient care encounters as described below: .NIOSH approved particulate respirators with N-95 filters or higher can also be used by HCP working in other situations where additional risk factors for transmission are present such as the patient is unable to use source control (masks) and the area is poorly ventilated .To simplify implementation, facilities in counties with higher levels of SARS-COV-2 transmission may consider implementing universal use of NIOSH-approved particulate respirators with N-95 filters or higher for HCP during all patient care encounters or in specific units or areas of the facility at higher risk for SARS-COV-2 transmission .Eye protection (i.e., goggles or face shield that covers the front and sides of the face) worn during all patient care encounters. Review of the COVID-19: Identification and Care of Resident with Suspected or Confirmed Virus policy, dated 6/27/23, revealed the facility will monitor residents for signs/symptoms of respiratory infection (cough, fever, sore throat) upon admission/readmission and daily during their stay in the facility during an outbreak. If positive for fever or symptoms, implement recommended Infection Control Practices. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 10/11/23, at 10:45 a.m. revealed that as of 10/11/23, a total of five residents from the 2-West unit had tested positive for COVID and had been moved to the South Unit. Observations conducted on 10/11/23, between 11:05 a.m. and 11:40 a.m. on 2-West unit with the DON revealed the following: Housekeeping Staff Employee E1 cleaning inside a resident room with a surgical mask on their face and isolation gown. Page 1 of 2 395003 395003 10/11/2023 Quality Life Services - New Castle 520 Friendship Street New Castle, PA 16101

F 0880 Level of Harm - Minimal harm or potential for actual harm Nurse Aide (NA) Employee E2 entering a resident room to answer a call bell with only a surgical mask on the face. NA Employee E4 was observed in a room at a resident bedside assisting the resident with care with only a surgical mask on their face. Residents Affected - Some The DON confirmed that the staff should be wearing a surgical mask with a face shield or an N-95 mask with goggles or face shield at the time of each observation as indicated above. Staff later obtained the face shields from the closet during the observations. During an interview on 10/11/23, at 1:58 p.m. the NHA confirmed that the facility follows the Pennsylvania Department of Health 2023-PAHAN-694-05-11-UPD, and the staff on 2-West should be wearing N-95 masks and face shields or goggles unless they are not fit tested (specified testing to wear an N-95 mask). If not fit tested for an N-95 mask, the staff should have on a surgical mask and face shield until the staff are fit tested for an N-95 mask. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa Code 211.12(1)(3) Nursing services 395003 Page 2 of 2