Health inspection·November 5, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety Based on facility policy review, review of manufacturer's instructions, clinical record review, observation, and staff interview, it was determined that the facility failed to implement proper infection control procedures regarding the use and disinfection of a multi-use blood glucose meter (BGM) for four of 21 residents that utilized one of two medication carts on the nursing unit. This resulted in an Immediate Jeopardy situation due to an increased likelihood of transmitting bloodborne pathogens between residents who required fingerstick blood glucose testing. (Residents 38, 42, 43, 48)Findings include: Review of the facility policy entitled, Obtaining a Fingerstick Glucose Level, last reviewed October 1, 2025, revealed that blood glucose meters intended for reuse were to be cleaned and disinfected between resident uses according to the manufacturer's instructions and current infection control standards of practice. Review of manufacturer's instructions for the blood glucose meters used by the facility revealed that staff should clean the product with a commercially available Environmental Protection Agency (EPA) registered disinfectant detergent or germicide wipe. Clinical record review revealed that Resident 38 had diagnoses that included diabetes mellitus (a chronic disorder characterized by high blood sugar levels due the body's inability to produce or effectively use insulin) and viral hepatitis C (a viral infection that can be transmitted via bodily fluids, causes liver swelling, and can lead to serious liver damage). A physician's order dated August 14, 2024, directed staff to administer insulin lispro subcutaneously (insert a needle under the skin) based on a sliding scale (a method of managing diabetes by adjusting insulin doses in response to the individual's current blood glucose levels) four times a day. Clinical record review revealed that Resident 42 had diagnoses that included diabetes mellitus and human immunodeficiency virus (a virus that can be transmitted via bodily fluids and weakens the immune system by attacking and destroying cells that are essential for the body's ability to fight off infection). A physician's order dated December 31, 2024, directed staff to administer insulin lispro subcutaneously before meals based on a sliding scale. Clinical record review revealed Resident 43 had diagnoses that included diabetes mellitus and chronic viral hepatitis C. A physician's order dated September 19, 2025, directed staff to check resident's blood glucose level four times a day on Tuesdays, Thursdays, Saturdays, and Sundays, and three times a day on Mondays, Wednesdays, and Fridays. Clinical record review revealed Resident 48 had a diagnosis of diabetes mellitus. A physician's order dated July 8, 2024, directed staff to administer insulin lispro subcutaneously based on a sliding scale four times a day. Observations on November 5, 2025, at 8:30 a.m., revealed that licensed practical nurse 1 (LPN 1) prepared the blood glucose meter to obtain a blood glucose reading for Resident 48. LPN 1 wiped the blood glucose meter with a 70% isopropyl alcohol wipe and proceeded to use the device to test the resident's blood glucose. LPN 1 then cleaned the blood glucose meter with 70% isopropyl alcohol and put the device back in the top drawer of the cart. Observation of the medication cart that LPN 1 was using was checked at that time and no EPA registered disinfectant detergent or germicide wipes were present. In an interview at that time, LPN 1 stated that Residents Affected - Some Page 1 of 3 395077 395077 11/05/2025 Garden Spring Rehab and Care Center 1113 North Easton Road Willow Grove, PA 19090

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some she cleaned the blood glucose meter with 70% isopropyl alcohol wipes before and after testing each resident. Observation on November 5, 2025, at 10:07 a.m., revealed that LPN 1 again cleaned the blood glucose meter with a 70% isopropyl alcohol wipe and escorted Resident 38 to his room. In an interview with LPN 1 at that time, LPN 1 confirmed that she was going to use the blood glucose meter used earlier and cleaned with the 70% alcohol wipe to test the blood glucose level of Resident 38. LPN 1 confirmed that she was assigned to the medication cart servicing Residents 38, 42, 43, and 48 and that the blood glucose meter on the cart would be used to obtain blood glucose levels for all residents in the assigned rooms who required blood glucose checks. In an interview on November 5, 2025, at 10:20 a.m., the Director of Nursing (DON) stated that blood glucose meters were to be disinfected using available EPA germicidal disposable wipes and that blood sugar checks with a blood glucose meter were required when residents had physician's orders for sliding scale insulin. In an interview on November 5, 2025, at 3:00 p.m., the Infection Preventionist confirmed that facility staff were to use EPA germicidal disposable wipes to clean and disinfect the blood glucose meters. On November 5, 2025, at 2:40 p.m., the Administrator and the DON were notified that on November 5, 2025, at 10:07 a.m., the failure to implement proper infection control procedures regarding the proper use and disinfecting of blood glucose meters resulted in an Immediate Jeopardy situation at F880-K and the Immediate Jeopardy template was provided. The facility was informed that a corrective action plan was required. The facility presented an acceptable action plan for removal of the Immediate Jeopardy on November 5, 2025, at 6:38 p.m. The facility's action plan contained the following: 1. Facility was notified on 11/5/25 that LPN 1 was observed cleaning the glucometer device with 70% Isopropyl Alcohol wipes. LPN 1 was removed from schedule immediately and will not be returning to the facility. 2. Director of central supplies ensured that each of the eight medication carts had the disinfecting agents that meet the requirements of the Environmental Protection Agency (EPA) registered cleaning products as noted in the manufacturer's instructions. 3. The Medical Director was notified on 11/5/2025. 4. All nurses will be educated on the Obtaining a Fingerstick Glucose Level, policy and procedure. In addition, they will be educated on the necessity of using the approved EPA registered germicidal wipe as required in the manufacturer's instructions and where to obtain them, by 11:59 p.m., on 11/5/2025. Education provided by the DON/designee. No licensed nurse will be permitted to begin their shift until they have been educated on the proper use and disinfection of the glucometer. 5. Newly hired licensed nurses will be educated at orientation on the Obtaining a Fingerstick Glucose Level, policy and procedure using the approved EPA registered germicidal wipe requirements as noted in the manufacturer's instructions. All agency licensed nurses will be educated before they begin their first shift in the facility. 6. Central supply department received education on 11/5/2025, regarding ensuring that the EPA germicidal wipes are in the carts. 7. DON/designee will complete random glucometer cleaning and disinfecting observation audits daily for seven days plus weekly for four weeks and monthly for three months ensuring education has been effective. 8. DON/designee will be monitoring steps of the action plan for continued compliance. 9. Central supply/designee will monitor three times a week ensuring the EPA germicidal wipes are in the carts. 10. Audits will be brought to QA&A for review and recommendations. 11. QAPI committee will determine the need for further audits. The survey team validated that Immediate Jeopardy was removed on November 5, 2025, at 6:38 p.m., through observation, review of the facility training, and staff interviews following the facility's implementation of the plan for removal of the Immediate Jeopardy. The deficient practice remained at scope/severity E (pattern with potential for more than minimal harm) following the removal of the Immediate Jeopardy. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 395077 Page 2 of 3 395077 11/05/2025 Garden Spring Rehab and Care Center 1113 North Easton Road Willow Grove, PA 19090

F 0880 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 395077 Page 3 of 3