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
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
395080
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395080
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Phoebe Allentown Health Care Center
1925 Turner Street
Allentown, PA 18104
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395080
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395080
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Phoebe Allentown Health Care Center
1925 Turner Street
Allentown, PA 18104
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Nursing services.
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395080
If continuation sheet
Page 3 of 3