Health inspection·August 1, 2024

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 review of facility policy, observations, and interviews with staff, it was determined that the facility failed to maintain proper infection control practices to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents reviewed. (Resident R1) Residents Affected - Few Findings Include: Review of the facility policy titled, Infection Transmission Prevention and Interventions undated states The facility has established and will maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. iii. Droplet precautions 1. These precautions protect staff, visitors, and other residents from droplets that are expelled during coughing, sneezing, or talking. 2. Masks are to be worn when working in close proximity to the resident. 3. Specific guidelines may be needed during the transport and placement of residents. The environmental management of equipment, etc. should be used according to each category's requirement. Review of facility training for Droplet Precautions, Hand Hygiene-Why it Matters, Respiratory Illness Refresher/Guidance and Tool Kit for Respiratory Pathogens trainings completed with staff during the month of July 2024 revealed only licensed nurses and nurse aides were trained and signed off on being trained. Interview held with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 at 9:20 a.m. to obtain access to clinical records and facility information. At this time the signage in the lobby regarding an Upper Respiratory Infection outbreak was discussed. Employee E1 and Employee E2 stated that during the month of July 2024 there was an outbreak of the HIB (Haemophilus Page 1 of 3 395818 395818 08/01/2024 Masonic Village at Lafayette Hill 801 Ridge Pike Lafayette Hill, PA 19444

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Influenzae Disease) virus. Review of reportable documentation submitted to the Department of Health from July 17, 2024 revealed Starting on July 5, 2024 some of the healthcare center residents started showing signs of respiratory illness. Infection control policies and procedures were implemented and remain ongoing. Residents were placed into isolation, testing completed per CDC guidelines. PCR sent to lab. Per our previous reports, 3 cases over the time since July 5 were positive for COVID however all other testing was coming back negative. Over the course of this time since 7/5, 32 residents have presented with respiratory illness and testing continued to result negative including testing for Legionella. On July 16, 2024, the DON received a call from public health department to report a positive swab they obtained from CHH on a resident that lives in our retirement living section. The swab was positive in the hospital for Haemophilis Influenzae. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Acute Embolism, Acute Respiratory Failure with Hypoxia, Essential Hypertension, Dysphagia, Chronic Pain, Hearing loss, Lack of Coordination, Osteoporosis, Cognitive Communication deficit, Abnormalities of Gait, Urinary Incontinence, and a contracture of the left knee. Resident R1 was put on isolation and on droplet precautions on July 31, 2024 for wheezing and possibility of infection. During observations on the unit signage stating Before entering this room, please see the nurse, thank you and PPE (personal protective equipment) was observed outside of the resident R1's room. During observation outside of the resident's room, two staff were observed going into the room without putting on appropriate PPE. Observation of the second-floor unit revealed a licensed nurse, Employee E5 went into resident R1's room after putting on PPE including a mask, face shield, and gloves at 10:08 a.m. At 10:09 a.m. a contracted phlebotomist worker went into Resident R1's room with mask on without putting on additional PPE including gloves and a face shield. A minute later the phlebotomist came out of the resident's room and started to look in the drawers for PPE. The licensed nurse Employee E5 then came out of the room and asked the phlebotomist if she could not find the appropriate PPE. Employee E4 stated that she could not find any face shields in the drawers and license nurse Employee E5 stated that she would retrieve some. Interview held with the phlebotomist revealed that she was not aware precautions were needed as she was just here to obtain the resident's blood samples. The phlebotomist was asked if she was obtaining samples for any other residents in the building today and she stated, no. The phlebotomist was asked if she was aware Resident R1 was on droplet precautions, and she stated no. Interview held with licensed nurse Employee E5 who confirmed that Resident R1 was on isolation and droplet precautions which required staff to wear a mask, face shield, and gloves when entering the resident's room. The phlebotomist on August 1, 2024 at 10:12 a.m. put on a face shield and gloves and went back into Resident R1's room. After obtaining a blood sample, the phlebotomist left Resident R1's room, took off her gloves at the PPE station outside of the room and placed the gloves into her sweatshirt pocket. The phlebotomist then put on new gloves and went back into the resident's room. At 10:16 a.m. the phlebotomist left the resident's room without gloves but still wearing a mask and a face shield. The phlebotomist took off the face shield, hung it around her wrist and walked off the unit with it. At 10:19 a.m. a nurse practitioner, Employee E3 knocked on the door and went into Resident R1's room without putting on any PPE. Employee E3 had no mask, no face shield, and no gloves on. Employee E3 came out of Resident R1's room at 10:25 a.m. Employee E3 was asked how come she went into the room without PPE and nurse practitioner Employee E3 stated, I'm sorry, I was not aware, I was only aware that the resident was having nausea. 395818 Page 2 of 3 395818 08/01/2024 Masonic Village at Lafayette Hill 801 Ridge Pike Lafayette Hill, PA 19444

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview held with the Director of Nursing Employee E1 at 12:10 p.m. and confirmed that all staff going into any resident room with droplet precautions should wear PPE into the room and the worn PPE should be discarded prior to leaving the resident's room. The facility was unable to provide evidence that nurse practitioner Employee E3 and phlemobotomist were made aware of Resident R1's droplet precaution status prior to them having contact with the resident on August 1, 2024. 28 Pa Code 211.12(d)(1)(3)(5) Nursing services 395818 Page 3 of 3