Health inspection·August 19, 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, observation, staff interview, and a review of manufacturer's instructions, it was determined that the facility failed to implement proper infection control regarding the proper use and disinfection of multi-use blood glucose meters (BGM) for one of seven sampled residents (Resident 1), and on six of six nursing units. This resulted in an Immediate Jeopardy situation due to an increased likelihood of transmitting bloodborne pathogens between residents who required fingerstick blood glucose testing. Findings include:Review of the facility policy entitled, Blood Glucose Meter Testing, last reviewed, October 16, 2024, revealed that blood glucose testing using a meter would be done in accordance with federal regulations. Review of the Centers for Disease Control and Prevention article entitled, Considerations for Blood Glucose Monitoring and Administration, dated August 7, 2024, revealed that BGMs were to be assigned to a person unless the meter was designed for use in professional settings and cleaned and disinfected after every use. BGMs were to be cleaned and disinfected after every use per the manufacturer's guidelines. These recommendations were applicable for long-term care settings. Review of an EPA article entitled, Registered Antimicrobial Products Effective Against Bloodborne Pathogens: Human immunodeficiency virus (HIV), Hepatitis B, and Hepatitis C, last reviewed June 16, 2025, revealed that isopropyl alcohol alone, without the addition of another agent, was not listed as a registered product effective against those bloodborne pathogens.Review of manufacturers' instructions for the two BGMs used by the facility, True Metrix and Leader LE1, revealed that both brands of BGMs were for single patient use only and should not have been used for multiple patients. Both BGMs were to be cleaned with an Environmental Protection Agency (EPA) registered disinfectant. The True Metrix BGM was to be cleaned with Super Sani Cloths. The Leader LE1 BGM was to be cleaned with DisCide Ultra Disinfecting towelettes.In an interview with a representative of the manufacturer of the True Metrix BGM on August 19, 2025, at 930 a.m., the representative stated that the True Metrix BGM was not to be used for multiple patients and facilities should have obtained the BGM that was approved for use on multiple patients.In an interview with a representative of the manufacturer of the Leader LE1 BGM on August 19, 2025, at 9:43 a.m., the representative stated that the Leader LE1 BGM was not for use on multiple patients and facilities should have obtained the BGM that was approved for use on multiple patients.In interviews on August 19, 2025, between 8:15 a.m. and 8:37 a.m., Licensed Practical Nurses (LPN) 3, 4, 5, and 6, stated that they cleaned the True Metrix and Leader LE1 BGMs with 70 percent (%) isopropyl alcohol wipes. LPN 4 and 6 stated that the isopropyl alcohol wipes were the only disinfectant wipes available on the unit to clean the BGMs and there were no additional disinfectant wipes or agents available for use. LPN 4 also confirmed that the BGMs in the medication cart were used for multiple residents and were not designated for specific residents. Observations of LPN 4 and 5's medication carts during that period revealed that there were no EPA approved disinfectants available in the medication carts that would meet the manufacturer's instructions for cleaning the BGMs.On August 19, 2025, at 8:08 a.m., the Assistant Director of Nursing (ADON) was Residents Affected - Some Page 1 of 3 395080 395080 08/19/2025 Phoebe Allentown Health Care Center 1925 Turner Street Allentown, PA 18104

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some observed providing education to LPN 2 and LPN 3 that included instruction that blood glucose meters should be cleaned with 70% isopropyl alcohol wipes. The education was not in accordance with the manufacturer's instructions for cleaning the BGMs.On August 19, 2025, at 10:24 a.m., LPN 5 prepared a Leader LE1 BGM to obtain a blood glucose reading on Resident 1. LPN 5 wiped the BGM with a 70% isopropyl alcohol wipe and proceeded into the resident's room. In an interview at that time, LPN 5 confirmed that only the 70% isopropyl alcohol wipe was used to clean the device.In an interview on August 18, 2025, at 2:35 p.m., the Director of Nursing (DON) stated that the BGMs in the facility were used for multiple patients. In an interview on August 19, 2025, at 10:34 a.m., the DON confirmed that the facility was using only 70% isopropyl alcohol wipes to clean all glucometers, that the manufacturer's instructions for both brands of BGMs used in the facility (True Metrix and Leader LE1) specified that EPA registered disinfectant wipes were to be used, and that the instructions did not include 70% isopropyl alcohol wipes as an approved agent to disinfect the BGMs.In an interview on August 19, 2025, at 3:50 p.m., the Infection Preventionist confirmed that the facility was using only 70% isopropyl alcohol wipes to clean the BGMs.Review of facility documentation revealed that 51 of 233 residents had current physicians' orders for fingerstick blood glucose monitoring.On August 19, 2025, at 11:21 a.m., the Administrator and DON were notified that on August 19, 2025, at 11:15 a.m., the failure to implement proper infection control procedures regarding the proper use and disinfecting of blood glucose meters (BGM) 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 August 19, 2025, at 4:54 p.m. The facility's action plan contained the following:1. All single patient use BGMs were removed from use and replaced with BGMs designed for multiple patient use. Disinfectant agents that meet requirements of the EPA registered products as noted in the manufacturer's instructions were provided to the nursing units.2. Licensed staff on duty in the facility were educated on the proper use and cleaning of multiple patient BGMs using EPA registered disinfecting agents, in accordance with manufacturer's instructions.3. All licensed staff will be educated on the proper use and cleaning of multiple patient BGMs before the start of their shift, until 100% of staff have been educated. No staff will be scheduled to work until they have been educated on the proper use and cleaning of multiple patient BGMs.4. The facility policy and procedure entitled, Blood Meter Testing, was revised to include the use of multiple patient use BGMs and cleaning procedures that are in accordance with CDC, EPA, and manufacturer's guidelines.5. The facility will only use multiple patient use glucometers that are cleaned with the EPA registered disinfectant agents per the manufacturer's instructions.6. The facility will conduct ongoing audits of the use and cleaning of BGMs for three months; the results will be reported to the Quality Assurance and Performance Improvement committee.7. The Administrator or designee will monitor the steps of the action plan for continued compliance.8. The DON educated the ADON on the proper use and cleaning of multiple patient BGMs to equip the ADON with proper information to provide staff education.9. The diabetic competency for new hires will be reinstated and include the proper use and cleaning of multiple patient BGMs in accordance with the manufacturer's instructions.The survey team validated that Immediate Jeopardy was removed on August 19, 2025, at 4:54 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 211.10(a)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(5) 395080 Page 2 of 3 395080 08/19/2025 Phoebe Allentown Health Care Center 1925 Turner Street Allentown, PA 18104

F 0880 Nursing services. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 395080 Page 3 of 3