EBENSBURG, PA - Federal health inspectors cited Cambria Care Center after documenting staff members failing to follow mandatory infection control protocols designed to prevent the spread of dangerous antibiotic-resistant bacteria among vulnerable residents.
The January 30, 2025 inspection revealed that nursing staff provided care to a quadriplegic resident with an indwelling urinary catheter without wearing required protective equipment, despite clear orders requiring enhanced barrier precautions.
Staff Observed Violating Protective Equipment Requirements
Inspectors documented a specific incident on January 28, 2025, when a nurse aide emptied the catheter drainage bag for a quadriplegic resident who was under enhanced barrier precautions. The staff member wore only gloves during the procedure and failed to wear the required gown, despite signage posted on the resident's door clearly listing catheter care as a high-contact activity requiring both gloves and gown.
The same aide then performed hand hygiene, put on new gloves, and assisted the resident with repositioning in bed—again without wearing a gown as required by the facility's protocols.
The resident's medical record indicated a diagnosis of quadriplegia and dependence on an indwelling urinary catheter for bladder management. Physician orders dated December 29, 2024, specifically required enhanced barrier precautions for all care activities with this resident.
Understanding Enhanced Barrier Precautions
Enhanced barrier precautions represent a targeted infection control strategy implemented in nursing homes to reduce transmission of multidrug-resistant organisms—bacteria that have developed resistance to commonly used antibiotics. These organisms pose particular risks in long-term care facilities, where residents often have compromised immune systems, chronic medical conditions, and indwelling medical devices that create pathways for infection.
The Centers for Disease Control and Prevention updated guidance in 2024 to require enhanced barrier precautions for residents with indwelling medical devices such as urinary catheters, regardless of whether they have a known infection. This preventive approach recognizes that residents with catheters face elevated risks both for acquiring resistant infections and for transmitting organisms to other residents and staff.
Urinary catheters create a direct pathway from the external environment into the bladder, bypassing natural defense mechanisms. Bacteria can migrate along the catheter surface or be introduced during handling of the drainage system. Once established in the urinary tract, these organisms can multiply and spread to the bloodstream, potentially causing life-threatening sepsis.
Medical Risks of Protocol Failures
When staff members handle catheter systems without appropriate protective barriers, they risk transferring organisms from their clothing and skin to the resident's catheter and surrounding areas. The drainage bag contains concentrated urine that may harbor high levels of bacteria. Contact with this system without proper gowning creates opportunities for contamination.
For a quadriplegic resident, these risks intensify significantly. Spinal cord injuries typically impair bladder function, making long-term catheterization necessary but also creating persistent vulnerability to urinary tract infections. The inability to move independently means these residents depend entirely on staff for all hygiene and positioning needs, creating multiple daily opportunities for organism transmission if proper precautions are not followed.
Additionally, impaired sensation associated with quadriplegia means residents may not feel early symptoms of infection, allowing problems to progress before detection. The immune system changes that can accompany spinal cord injury may further reduce the body's ability to fight off infections once they occur.
Facility Had Clear Protocols in Place
The facility's own policy, dated December 30, 2024, outlined requirements for enhanced barrier precautions that aligned with federal CDC guidance. The policy specified that gowns and gloves must be worn during high-contact care activities including dressing, bathing, transferring, toileting assistance, device care, and wound care for residents with indwelling medical devices.
Signage posted directly on the resident's door listed the specific care activities requiring protective equipment, including urinary catheter care and repositioning—the exact activities inspectors observed being performed without proper protection.
The facility's infection control preventionist, a licensed practical nurse, confirmed during interview that the staff member should have worn both gown and gloves during the observed catheter care and repositioning activities.
Industry Standards for Catheter Care
National infection control standards emphasize the critical importance of barrier precautions during urinary catheter management. The catheter drainage system should be treated as a closed system to minimize contamination risk. Any manipulation of the system—including emptying drainage bags, checking tubing, or adjusting catheter position—requires appropriate hand hygiene and protective equipment.
Standard protocols require staff to avoid touching the drainage spout to any surface, empty bags regularly to prevent backflow, and maintain the bag below bladder level at all times. When enhanced barrier precautions are in effect, these technical requirements combine with the additional mandate for gown and glove use during all catheter-related activities.
The positioning assistance observed during the inspection also qualified as a high-contact activity under the facility's protocol. Transferring or repositioning residents involves sustained close contact and handling of skin surfaces, bedding, and medical devices—all potential routes for organism transmission.
Kitchen Equipment Maintenance Issues Documented
Inspectors also identified problems with essential equipment maintenance in the facility's kitchen. Multiple pieces of critical food service equipment were found to be non-operational or functioning improperly, some for extended periods.
The primary dishwashing machine was not registering temperature during its first rinse cycle and was leaking water onto the floor—issues that had persisted since September 2024. A steam kettle had been broken since June 2024, requiring placement of a bucket underneath to catch leaking water.
Additional equipment problems included an upright cooler out of service since May 2024, a garbage disposal creating loud noises and not being used, an oven non-operational since March 2024 due to a broken door pin, a second oven with a malfunctioning on-off switch but still in use, and both pressure cookers non-functional—one since August 2024 and the other since September 2024.
The dietary manager confirmed these issues and stated that alternative cooking equipment was being used and that meal service had not been adversely affected. However, the extended timeline of equipment failures raised concerns about systematic maintenance oversight.
Proper functioning dishwashing equipment is essential for food safety in institutional settings. Commercial dishwashers must reach specific temperatures during wash and rinse cycles to ensure effective sanitization of dishes, utensils, and food preparation equipment. When temperature monitoring systems fail, there is no reliable way to verify that sanitization standards are being met.
Regulatory Citations
The facility received citations under federal tag F880 for failure to provide and implement an effective infection prevention and control program, and tag F908 for failure to maintain essential equipment in safe operating condition.
Both violations were classified as causing minimal harm or potential for actual harm. The infection control violation affected a small number of residents, while the equipment maintenance issues had facility-wide implications.
Inspectors also referenced multiple Pennsylvania state regulations, including requirements related to licensee responsibility, management standards, and nursing services.
Broader Implications
The documented infection control failure represents a breakdown in multiple safety systems. The facility had appropriate policies, physician orders were in place, clear signage was posted, and staff had access to necessary protective equipment. Despite these safeguards, protocol adherence failed at the point of care delivery.
This gap between written protocols and actual practice patterns poses risks beyond the single observed incident. If staff routinely skip required precautions during catheter care and repositioning, the potential for pathogen transmission multiplies across all residents under enhanced barrier precautions and extends to other vulnerable residents throughout the facility.
The equipment maintenance issues similarly suggest systematic problems with facility oversight and resource allocation. When essential kitchen equipment remains non-operational for periods ranging from several months to nearly a year, it indicates inadequate prioritization of infrastructure maintenance that supports basic resident care functions.
Facility Details: Cambria Care Center, also operating as Maple Heights Health & Rehab Center, LLC, is located at 429 Manor Drive in Ebensburg, Pennsylvania. The facility identification number is 395828.
For complete details of the inspection findings and the facility's correction plan, the full survey report is available through the Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cambria Care Center from 2025-01-30 including all violations, facility responses, and corrective action plans.
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