Health inspection·March 5, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of five residents reviewed (Resident 1). Residents Affected - Few Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The facility's policy regarding EBP, dated May 8, 2024, indicated that EBP's would be indicated for residents with wounds or indwelling medical devices, and infection or colonization with an MDRO. Healthcare personnel were to wear appropriate PPE, including gloves and gowns, when providing care to residents requiring EBP's. The facility's pharmacy policy regarding medication administration, dated May 8, 2024, indicated that staff were not to touch tablets or capsules with their fingers. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 26, 2025, indicated that the resident was cognitively impaired, required assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), received insulin injections, and had diagnoses that included diabetes and neurogenic bladder (bladder lacks control due to nerve or muscle problems). A physician's order and care plan for Resident 1, dated February 19, 2025, included an order for the resident to have a urinary (foley) catheter (an indwelling catheter) and EBP's for the use of the Page 1 of 2 395514 395514 03/05/2025 Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indwelling catheter. The physician's orders also included orders for the resident to receive 27 units of Insulin Glargine subcutaneously (beneath the skin) one time a day for diabetes, 4 percent Lidocaine External Patch to be applied to the lower back topically one time a day for pain, and 0.4 milligrams/hour Nitroglycerin Transdermal Patch to be applied one time a day for angina (chest pain). Observations of medication pass on March 5, 2025, at 9:40 a.m. and 10:04 a.m. revealed that Licensed Practical Nurse 1, while not wearing gloves, spilled a cup of prepared medications onto the top of the medication cart, picked them up and put them back into the cup, and administered them to Resident 1. She continued to feel Resident 1's lower back and applied the Lidocaine patch, cleaned the resident's abdomen with alcohol and administered his Insulin Glargine, and removed the Nitroglycerin patch from his right upper chest. During the medication pass Licensed Practical Nurse 1 dropped the Lisinopril pill onto the floor and returned to the medication cart to prepare another dose. While preparing the dose of Lisinopril, without gloves on, she spilled the pill onto the top of the medication cart and picked it up with her fingers, put it back into the medication cup and administered it to the resident. She then applied the Nitroglycerin patch to the resident's left upper chest. Licensed Practical Nurse 1 did not wear any PPE during the administration of medications to Resident 1. Interview with Licensed Practical Nurse 1 on March 5, 2025, at 10:12 a.m. revealed that she did not think that Resident 1 was on EBP and that she never wears gloves when administering insulin pens or applying medicated patches, and confirmed that she did not use gloves when touching the resident's spilled medication, since her hands had been washed prior. Interview with the Director of Nursing on March 5, 2025, at 1:55 p.m. confirmed that Resident 1 was on EBP, and that Licensed Practical Nurse 1 should have been wearing a gown and gloves while providing direct care to the resident. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395514 Page 2 of 2