Health inspection·January 14, 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 facility policy, observation, and staff interviews, it was determined that the facility failed to implement infection prevention and control monitoring policies for Respiratory Precautions for one of three residents (Resident R1), failed to prevent cross contamination by having dirty linens on the floor for one of eight residents (Resident R1), failed to maintain sanitary commodes in bathrooms for three of eight residents (Residents R2, R3, and R5), and failed to ensure floor mats were clean for four of eight residents (Residents R4, R6, R7, and R8). Residents Affected - Few Findings include: Review of the CDC (Center for Disease Control) Fact Sheet Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected Covid-19 indicated doffing - (taking off the gear) Remove gloves and gown. Healthcare Personnel may now exit patient room. Next, remove face shield or goggles and remove and discard respirator. Perform hand hygiene after removing the respirator and applying a new one. Review of the facility policy Cleaning and Preventative Maintenance, Resident Rooms and Equipment dated 1/2/25, indicated it is the facility's policy to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. This policy is part of the facility's overall Infection Prevention and Control Program. Review of the facility provided Precaution List dated January 2025, indicated the 3East unit had three residents in Respiratory Precautions for either being covid positive or still symptomatic of respiratory illness. During an interview on the 3 East unit, on 1/14/25, at 9:42 a.m. the following staff were asked what PPE was required with a Respiratory Precaution resident? Staff present were Registered Nurse (RN) Employee E1, Licensed Practical Nurse (LPN) Employee E2, LPN Employee E3, and LPN Employee E4. The response was appropriate until the doffing (removal) of the N95 respirator. The group indicated staff should remove the N95 mask inside the Respiratory Precautions room along with the other PPE (gown, gloves, and goggles/face shield), not immediately outside the room as required, and performing hand hygiene before donning (applying) a new N95. Interview on 1/14/25, at 9:44 a.m. RN Employee E1 indicated she was unaware of this practice and inquired if it was new. Observations during a tour of the 3 East unit on 1/14/25, at 10:10 indicated the following: -Resident R1 in 386W had a Precautions sign on the door. Inside the room across from the foot of Page 1 of 3 395606 395606 01/14/2025 John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237

F 0880 Level of Harm - Minimal harm or potential for actual harm the bed was a pile of soiled linens on the floor and under the sink by the door entrance had a pile of soiled linens on the floor. -Resident R2 in 385D had dried specs of brown substance in the toilet bowl and on the outside of the commode. Residents Affected - Few -Resident R3 in 392W had dried brown substance at the base of the commode. Interview during a tour with LPN Employee E2 confirmed the findings above for Resident R1, R2 and R3. Observations during a tour of the 2 East unit on 1/14/25, at 11:22 a.m. indicated the following: -Resident R4 in 293W had floor mats (placed on floor beside bed to prevent fall injuries) covered in debris. Interview on 1/14/25, at 11:24 a.m. Nurse Aide (NA) Employee E5 confirmed the floor mat for Resident R4 was not clean. Further observations during a tour of the 2 East unit on 1/14/25, at 11:30 a.m. indicated the following: -Resident R5 in 284W's bathroom commode had brown substance at the base and front edge of the toilet bowl. -Resident R6 in 281D floor mat along with the underside of the bed frame was caked with a thick layer of dried food substance. Interview during a tour with LPN Employee E6 confirmed the findings above for Resident R5 and R6. Continued observations during a tour of the 2 East unit on 1/14/25, at 11:35 a.m. indicated the following: -Resident R7 in 271W floor mat dirty with dirt and dried smudges over the surface. -Resident R8 in 270W floor mat dirty with dirt and dried smudges over the surface. Interview on 1/14/25, at 11:36 a.m. NA Employee E7 confirmed the findings above for Resident R7 and R8. Interview on 1/14/25, at 2:30 p.m. the Director of Nursing confirmed the facility failed to implement infection prevention and control monitoring policies for Respiratory Precautions for one of three residents (Resident R1), failed to prevent cross contamination by having dirty linens on the floor for one of eight residents (Resident R1), failed to maintain sanitary commodes in bathrooms for three of eight residents (Residents R2, R3, and R5), and failed to ensure floor mats were clean for four of eight residents (Residents R4, R6, R7, and R8). 28 Pa Code: 201.14 (a) Responsibility of licensee. 395606 Page 2 of 3 395606 01/14/2025 John J Kane Regional Center-Ro 110 McIntyre Road Pittsburgh, PA 15237

F 0880 28 Pa Code: 201.18 (b)(1) Management. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code: 201.20 (a)(c) Staff development. 28 Pa. Code: 211.10 (d) Resident care policies. Residents Affected - Few 28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services. 395606 Page 3 of 3