Manorcare Health Services-jersey Shore

F-F880

28 Pa Code: 201.18(e )(1)(2) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 395359 Department of Health & Human Services Printed: 08/27/2025 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 395359 B. Wing 05/16/2025

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

Jersey Shore Skilled Nursing and Rehabilitation Ce 1008 Thompson Street Jersey Shore, PA 17740

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 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 38839 potential for actual harm Based on observation, clinical record review, and resident and staff interview, it was determined that the Residents Affected - Few facility failed to implement appropriate enhanced barrier precautions for one of 24 residents reviewed (Residents 52).

Findings included:

Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care.

Review of the facility's current policy entitled Enhanced Barrier Precautions, revealed it is the facility's policy to use EBP in addition to Standard Precautions (infection control practices used for all patients) when Contact precautions (heightened infection control measures to prevent the spread of infections) do not otherwise apply, or when a resident has a targeted multi-drug-resistant organisms (MDROs - bacteria that have developed resistance to one or more antimicrobial drugs). The policy also indicated when EBP are needed an appropriate EBP sign will be placed on the patient's room door, and personal protective equipment (PPE) should be readily accessible and located outside the patient's room. The PPE is to be used

during high contact patient care activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, device care, or assisting with toileting. Before exiting the room, the PPE is to be placed in the trash and hand hygiene performed upon exiting the room.

An observation of Resident 52's room on May 13, 2025, at 10:50 AM revealed the resident was out of the room. A sign was observed on the door to the room indicating Stop - Standard Precautions plus Droplet Precautions (infection control measures to prevent the spread of diseases that are transmitted through respiratory droplets), and to wear a gown, gloves, and mask to enter the room. There were no PPE bins containing gowns or masks outside the room or near the room, nor were any PPE disposal bins observed in

the room or directly outside the door to the room.

In an interview with Employee 7, nurse aide, on May 13, 2025, at 11:21 AM who was working in the hallway where Resident 52 resided, indicated she was not sure why the sign was on Resident 52's door and was not aware Resident 52 or any of his roommates were on any precautions, and indicated the sign may not have been removed from flu season.

In an interview with the Nursing Home Administrator on May 13, 2025, at 12:33 PM it was determined that neither Resident 52 nor any of his roommates were to have Droplet Precautions and the sign was from an old instance and had not been removed from the door, but Resident 52 is to have EBP in place due to a history of an MDRO per the facility policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 395359 Department of Health & Human Services Printed: 08/27/2025 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 395359 B. Wing 05/16/2025

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

Jersey Shore Skilled Nursing and Rehabilitation Ce 1008 Thompson Street Jersey Shore, PA 17740

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 Clinical record review for Resident 52 revealed the resident has a history of draining wounds on his bilateral lower extremities, and per a lab report result dated December 31, 2024, the resident's wound culture was Level of Harm - Minimal harm or positive for Methicillin-Resistant Staphylococcus aureus (MRSA, bacteria resistant to several antibiotics, an potential for actual harm MDRO).

Residents Affected - Few An observation of Resident 52 on May 14, 2025, at 9:30 AM revealed the resident wheeling himself out of his room in a wheelchair. The Droplet Precautions sign on the door noted above had been removed and no signage appeared on the door indicating any additional precautions were needed for any of the resident's residing in Resident 52's room. Resident 52 was observed to have bandages wrapped around his lower legs.

In an interview with the Nursing Home Administrator on May 14, 2025, at 11:18, she indicated Resident 52 was indeed on EBP, and the signage should have been changed on the resident's door to the room with PPE supplies placed outside the room, when it was brought to the facility's staff attention on May 13, 2025.

Clinical record review for Resident 52 on May 15, 2025, at 12:31 PM revealed Special Instructions were now added in Resident 52's electronic record indicating the resident was to have EBP for draining wounds.

In an interview with the Nursing Home Administrator and Director of Nursing on May 15, 2025, at 2:30 PM it was confirmed Resident 52 should have had EBP in place with appropriate signage on the resident's door and availability of the required PPE should have been available outside the resident's room.

An observation of Resident 52's room on May 16, 2025, at 12:27 PM revealed no signage indicating EBP was located on Resident 52's door to alert staff and visitors that additional precautions were needed for the resident prior to entering the room nor were the required PPE supplies located outside the room and readily available.

Cross refer

F-F882

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 395359 Department of Health & Human Services Printed: 08/27/2025 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 395359 B. Wing 05/16/2025

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

Jersey Shore Skilled Nursing and Rehabilitation Ce 1008 Thompson Street Jersey Shore, PA 17740

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 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 36798

Residents Affected - Some Based on staff interview, it was determined that the facility failed to have a designated Infection Preventionist with the necessary qualifications responsible for the facility's infection prevention and control program.

Findings include:

Interview with the Nursing Home Administrator on May 13, 2025, at 9:15 AM revealed that the facility's previous Director of Nursing fulfilled the position of infection preventionist until July 2024, at which time she stepped down as the Director of Nursing into another position within the facility and is no longer employed by

the facility. The interview indicated that the facility currently does not have an infection preventionist and has not had one since July 2024.

Interview with the Nursing Home Administrator on May 15, 2025, at 2:30 PM confirmed the above findings regarding the infection preventionist position.

28 Pa. Code 201.18(b)(1)e)(1)(3)(6) Management

28 Pa. Code 201.19(3) Personnel policies and procedures

28 Pa. Code 211.12(c)(d)(1)(4)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 395359 Department of Health & Human Services Printed: 08/27/2025 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 395359 B. Wing 05/16/2025

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

Jersey Shore Skilled Nursing and Rehabilitation Ce 1008 Thompson Street Jersey Shore, PA 17740

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 36798

Residents Affected - Few Based on clinical record review and staff interview, it was determined that the facility failed to offer and administer a COVID immunization for one of five residents reviewed for immunizations (Resident 69).

Findings include:

Clinical record review revealed the facility admitted Resident 69 on October 8, 2024. Review of Resident 69's clinical record revealed no documentation of any COVID-19 vaccines.

Review of Resident 69's COVID 19 vaccine consent form date October 8, 2024, revealed a signed consent requesting the facility administer the current CDC recommended COVID vaccine. There was no additional information in Resident 69's clinical record that the facility offered or administered Resident 69 a COVID immunization since admission October 8, 2024.

Interview with the Nursing Home Administrator on May 16, 2025, at 10:35 AM confirmed these findings.

28 Pa. Code 211.5(f) Medical records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 395359