Athens Health And Rehabilitation Center

F-F3502-21 (voluntary standard for mask manufacturers) requirements including Workplace Performance and Workplace Performance Plus masks; or a well-fitting facemask. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved particulate respirators with N95 filters or higher

during the care of a patient with SARS-CoV-2 (COVID-19) infection, or during care of a patient on droplet precautions), they should be removed and discarded after the patient care encounter and a new one should be donned. Source control is recommended for individuals in healthcare settings who have suspected or confirmed SARS-CoV-2 infection.

CDC Transmission-Based Precautions, https://www.cdc. gov/infection-control/hcp/basics/transmission-based-precautions.html, note that the recommendation is to use droplet precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. The CDC sign for droplet precautions indicates that everyone must make sure their eyes, nose, and mouth are fully covered

before room entry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 396137 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 396137 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Athens Nursing and Rehabilitation Center 200 South Main St Athens, PA 18810

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Observation of Resident 1's room doorway on August 1, 2024, at 12:15 PM revealed a sign for contact precautions (use of a gown and gloves for all interactions that involve contact with the resident or resident's Level of Harm - Minimal harm or environment). The sign included handwritten, Droplet, in black marker over the word, Contact. The sign for potential for actual harm contact precautions did not include reference to eye protection. The door included a yellow PPE organizer that included gowns, gloves, surgical masks, and N95 masks. Residents Affected - Some Clinical record review for Resident 1 revealed nursing documentation dated July 31, 2024, at 2:01 PM that Resident 1's nephew was updated on his positive COVID status.

Observation of Resident 3's room doorway on August 1, 2024, at 12:23 PM revealed a sign for contact precautions. The sign included handwritten, Droplet, in black marker over the word, Contact. The sign for contact precautions did not include reference to eye protection. The door included a yellow PPE organizer that included gowns, gloves, surgical masks, and N95 masks.

Clinical record review for Resident 3 revealed nursing documentation dated July 29, 2024, at 2:16 PM that Resident 3 tested positive for COVID during routine testing.

Interview with Employee 3 (registered nurse) on August 1, 2024, at 12:49 PM confirmed that Residents 1 and 3 were the only residents in the facility currently isolated for COVID-19 infection. Employee 3 confirmed that the signage on the doorways for Residents 1 and 3 did not include measures necessary for droplet precautions (eye protection); and that the facility used the sign intended for contact precautions and just overwrote the word, Contact, with, Droplet.

Observation of Resident 1's room on August 1, 2024, at 1:04 PM revealed Employee 2 (nurse aide) inside

the doorway removing personal protective equipment. Employee 2 removed a blue surgical (not N95) mask.

Interview with Employee 2 on August 1, 2024, at 1:05 PM indicated that she just finished emptying the urine storage bag for Resident 1's indwelling urinary catheter (catheter inserted through the penis and into the bladder to drain urine). Employee 2 confirmed that she needed to be within a few feet of Resident 1 to access his urine collection bag. Employee 2 stated that she, just grabbed the one on top (surgical mask versus N95 mask), and that the sign, doesn't say, which mask is required. Employee 2 verified N95 masks were available in the PPE organizer. Employee 2 questioned, Well, why do they have them (blue surgical masks) there?

The surveyor reviewed the above concerns regarding COVID isolation precautions during an interview with

the Nursing Home Administrator and Employee 1 (clinical consultant) on August 1, 2024, at 1:14 PM.

483.80(a)(1)(2)(4)(e)(f) Infection Control

Previously cited deficiency 6/14/24

28 Pa. Code 201.18(b)(3)(d)(e)(1) Management

28 Pa. Code 211.12(d)(1)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 396137