ALTOONA, PA - Federal inspectors found that Hilltop Healthcare and Rehabilitation Center failed to implement required infection control protocols for eight residents with medical devices and chronic wounds, potentially exposing vulnerable patients to dangerous infections for several months.
Delayed Implementation of Safety Protocols
The January 17, 2025 inspection revealed that the 700 S. Cayuga Avenue facility did not begin using Enhanced Barrier Precautions (EBP) until November 27, 2024, despite federal requirements that took effect April 1, 2024. The facility's Director of Nursing confirmed this delayed implementation during interviews with surveyors.
Enhanced Barrier Precautions require healthcare workers to wear gowns and gloves during high-contact care activities for residents with indwelling medical devices like catheters and feeding tubes, or those with chronic wounds. These measures are designed to prevent the transmission of multidrug-resistant organisms (MDROs) - bacteria that have become resistant to standard antibiotics.
Residents at Risk
Eight residents were affected by the facility's failure to follow federal infection control guidelines:
Residents with Indwelling Catheters: Four residents had urinary catheters for conditions including neurogenic bladder and urine retention. One resident had both a urinary catheter and a documented history of Extended-spectrum beta-lactamases (ESBL), a type of antibiotic-resistant bacteria found in urine. Another resident had a suprapubic catheter inserted directly through the abdomen into the bladder.
Residents with Feeding Tubes: One resident with Parkinson's disease required tube feeding through a percutaneous endoscopic gastrostomy (PEG) tube but did not receive Enhanced Barrier Precautions until the November implementation date.
Residents with Chronic Wounds: Multiple residents had pressure ulcers and surgical wounds that required specialized care protocols that were not properly implemented.
Improper Wound Care Procedures
Surveyors observed concerning practices during wound care for a resident with quadriplegia who had pressure ulcers on both hips and a nephrostomy tube. On January 17, 2025, inspectors documented that a Licensed Practical Nurse:
- Changed gloves without performing hand hygiene between tasks - Provided incontinence care after the resident had a bowel movement - Cleaned fecal matter from a pressure ulcer without proper hand hygiene - Moved between caring for the nephrostomy site and wound care without following infection control protocols
When interviewed, the nurse acknowledged not performing hand hygiene between glove changes and between dirty and clean tasks. The facility's Infection Preventionist confirmed that hand hygiene should have been completed between these activities.
Missing Safety Equipment and Signage
For one resident with methicillin-resistant staphylococcus aureus (MRSA), inspectors found no personal protective equipment or warning signage posted outside the room, despite physician orders for contact isolation. The resident, who was receiving intravenous antibiotic treatment for a bone infection and had undergone foot surgery, told surveyors about her MRSA diagnosis and current wound vacuum therapy.
A Registered Nurse confirmed the resident should have been on contact precautions with proper signage and PPE supplies available outside the room, but indicated these safety measures had been removed by someone.
Medical Risks and Consequences
The failure to implement Enhanced Barrier Precautions creates significant health risks for nursing home residents, who are already vulnerable to infections due to age, medical conditions, and compromised immune systems. Residents with indwelling medical devices face particularly high infection risks because these devices provide pathways for bacteria to enter the body.
Urinary catheters are associated with catheter-associated urinary tract infections (CAUTIs), which can lead to bloodstream infections, sepsis, and increased mortality rates. Feeding tubes pose risks for aspiration pneumonia and insertion site infections.
For residents with chronic wounds, improper infection control can lead to wound contamination, delayed healing, cellulitis, and systemic infections. The presence of antibiotic-resistant organisms like MRSA and ESBL compounds these risks, as treatment options become more limited and infections may not respond to standard antibiotics.
Federal Standards and Requirements
The Centers for Medicare & Medicaid Services (CMS) updated its infection prevention guidance effective April 1, 2024, specifically requiring Enhanced Barrier Precautions for residents with chronic wounds or indwelling medical devices, regardless of their infection status. This represents a shift toward more proactive infection prevention rather than reactive isolation after infections occur.
According to Centers for Disease Control guidelines, MDRO transmission is common in skilled nursing facilities, contributing to substantial resident illness and death, as well as increased healthcare costs. The facility's own policy, dated November 26, 2024, acknowledged these requirements and outlined proper procedures for EBP implementation, including clear signage and appropriate PPE use.
Industry Standards for Infection Control
Proper infection control in nursing homes requires multiple layers of protection. Hand hygiene remains the primary defense against infection transmission and should occur before and after resident contact, after removing gloves, and between different care activities for the same resident.
Enhanced Barrier Precautions represent an additional safeguard for high-risk residents. These protocols require healthcare workers to don fresh gowns and gloves before providing direct care, personal hygiene assistance, or wound care to residents with medical devices or chronic wounds.
Contact isolation precautions, when ordered for residents with confirmed infections like MRSA, require dedicated PPE supplies outside patient rooms and clear signage indicating the type of precautions needed. These measures protect both other residents and healthcare workers from exposure to dangerous pathogens.
Facility Response and Corrections
The facility acknowledged the delayed implementation of Enhanced Barrier Precautions and indicated that protocols were put in place starting November 27, 2024. However, this represented nearly eight months after the federal requirements took effect, potentially exposing residents to preventable infection risks during that period.
The inspection findings highlight the importance of timely compliance with evolving federal safety standards and the need for robust infection control training for nursing staff. Facilities must ensure that all personnel understand proper hand hygiene techniques, PPE usage, and the specific requirements for residents with different risk factors.
The Centers for Medicare & Medicaid Services has classified this as a minimal harm violation affecting some residents, indicating that while the potential for serious consequences existed, immediate jeopardy to resident safety was not identified during the inspection period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillview Healthcare and Rehabilitation Center from 2025-01-17 including all violations, facility responses, and corrective action plans.
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