Health inspection·February 21, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, observation, and staff interviews, it was determined that the facility failed to establish, implement and maintain an effective infection control program related to enhanced barrier precaution, relating to staff education, proper signage and available personal protective equipment (PPE) for three of three reviewed. (Resident 3, Resident R10, and Resident 129) Residents Affected - Few Finding includes: Review of facility policy titled Enhanced Barrier Precautions revealed that enhanced barrier is an approach to the use of personal protective equipment (PPE) to reduce transmission of Multi Drug Organisms between residents in skilled nursing facilities. Enhanced barrier precautions (EBP) expand the use of gowns and gloves beyond standard precautions. The strategy calls for healthcare personal to wear specific (PPE) during high contact resident t care activities for resident known to be infected or colonized with an MDRO as well as those with increased risk of MDRO, which includes any resident with a wound or indwelling medical device (e.g., central line, urinary catheter, feeding tube, tracheostomy, ventilator) Example of contact care activities include: dressing, bathing, and provide hygiene, changing linens, changing briefs, device care and wound care. Review of Center for Disease Control and Prevention (CDC) policy titled Enhanced Barrier Precautions in Skilled Nursing Facilities dated November 15, 2025, revealed the focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves and make PPE, including gowns and gloves, available immediately outside of the resident room. Further review of CDC policy titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) revealed Enhanced barrier precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both Page 1 of 3 395718 395718 02/21/2025 Waverly Heights 1400 Waverly Road Gladwyne, PA 19035

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. An effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) o For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves Make PPE, including gowns and gloves, available immediately outside of the resident room Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room) Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education Provide education to residents and visitors Observation conducted on February 18, 19, 20, and 21, 2025, revealed three residents' doors with signage on the door consisting of instructions that all see the nurse before entering no indication of precaution and no personal protective equipment (PPE) readily available at point of care were viewed. Review of facility documentation matrix implied that three residents were assessed to be requiring enhanced barrier precaution due to indwelling device and wounds. Review of Resident R10's minimum data set (MDS-federal mandated process for clinical assessment of all residents) dated January 20, 2025 revealed that Resident R10 was admitted into the facility on January 13, 2025 with diagnosis' including benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty) and obstructive uropathy (a urinary tract disorder that occurs due to obstructive urinary flow) and requiring the use of an indwelling catheter. Review of Resident R10's physician order revealed an order for enhanced barrier precaution dated February 19, 2025, one month after being admitted with a suprapubic urinary catheter. Review of Resident R3's quarterly Minimum Data Set, dated [DATE], revealed that Resident R3 was 395718 Page 2 of 3 395718 02/21/2025 Waverly Heights 1400 Waverly Road Gladwyne, PA 19035

F 0880 Level of Harm - Minimal harm or potential for actual harm admitted into the facility on October 4, 2024 with two pressure ulcers (areas of damaged skin and soft tissue injuries). Review of Resident R129's MDS quarterly Minimum Data Set, dated [DATE], revealed that Resident R129 was admitted into the facility on February 10, 2025, with a surgical wound. Residents Affected - Few Review of Resident R129's physician order revealed no order for enhanced barrier precaution. Interview with Licensed nurse, infection control preventionist, Employee E 6 on February 19, 2025, at 1:03 p.m. revealed that it is not facility policy that PPE is required during contact such as physical therapy or any contact other than wound care or indwelling device. Employee E6 stated that (PPE) is not required if wounds are covered. Furthermore, Employee E6 stated that is respectful of resident privacy not to place signage on the door that indicated the resident is on any precaution and (PPE) can be obtained at the nurse's station. Interview with Licensed nurse Employee E10 on February 21, 2025, at 8:50 a.m. revealed that this employee has not been educated on enhanced barrier precautions, is unaware of the precaution and what is required. Interview with Licensed nurse, Employee E 11 on February 21, 2025, at 09:00 a.m. revealed that this employee has not been educated on enhanced barrier precautions, did not have any knowledge regarding the precaution and why it is implemented, and believes the posted sign on specific residents door to see the nurse before enter were indicated those residents were receiving hospice program and may not want to be disturbed. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.12(d)(5) Nursing Services 395718 Page 3 of 3