Pennsylvania Department of Health
 HOLLIDAYSBURG VETERANS' HOME
Patient Care Inspection Results

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HOLLIDAYSBURG VETERANS' HOME
Inspection Results For:

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HOLLIDAYSBURG VETERANS' HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey  completed on June 11, 2026 it was determined that Hollidaysburg Veterans Home was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
 Plan of Correction:


483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to serve food that was palatable and at safe and appetizing temperatures.

Findings include:

The facility's policy regarding food temperatures, dated January 1, 2026, indicated that all hot foods were to be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F).

Interview with a group of residents on June 10, 2026 at 2:00 p.m. revealed that the hot food is served warm or cold and that asking staff to reheat it in the microwave takes too much time. They stated that the residents that eat in their rooms are served first causing the food that sits in the dining room to cool down before the residents in the dining room are served.

Interview with Resident 31 on June 8, 2026 at 12:14 p.m. revealed that the food is cold, the soup is always served cold, and that the plates are even cold.

Interview with Resident 48 on June 8, 2026 at 12:19 p.m. revealed that the food is cold. She said that the food is barely warm when it reaches her and gets very cold before she has the chance to eat it.

Interview with Resident 73 on June 8, 2026 at 12:10 p.m. revealed that the food is always cold. He stated that there are no plate warmers, no warm pallets for the plates to rest on, and no steam tables to keep the food warm.

Interview with Resident 89 on June 8, 2026 at 12:15 p.m. revealed that the food is cold no matter if he eats in his room or in the dining room. He stated that he prefers to have hot food and especially hot soup.

Observations in the North 1 dining room for the lunch meal service on June 10, 2026, at 11:53 a.m., revealed the lunch meal consisted of chicken tenders, mashed potatoes, corn, diced pears and a salad. The last resident to be served in the dining room was at 12:34 p.m. The test tray on June 10, 2026, at 12:35 p.m. revealed that the temperature of the chicken tenders was 141.0 degrees (F), mashed potatoes was 124.5 degrees (F) and the corn was 116.0 degrees (F). The mashed potatoes and corn were not hot and were not served at the appropriate temperatures.

Interview with Cook 6 on June 10, 2026, at 12:45 p.m. confirmed that food should be served at a temperature of 140 degrees (F) or higher.

28 Pa. Code 211.6(f) Dietary Services.






 Plan of Correction - To be completed: 07/13/2026

The facility policy for food temperatures will be reviewed and revised as necessary. The lower oven of the serving carts will be utilized for all hot foods in order to maintain adequate temperature. Supervisors will randomly check food temps throughout meal service and take correction action, as necessary.

Dietary staff will be education on Federal Regulation 804, the facility policy for food temperatures for dining room services, utilizing the lower over of the serving carts, and the importance of maintaining appropriate hot food temperatures. Food temperatures will be taken at the end of the meal period prior to disposal to assure temperatures were maintained.

Dietary Manager/designee will audit to observe for use of the lower oven of the serving carts and maintaining appropriate hot food temperatures during meal service, daily for two weeks, weekly for two months, and monthly for two months. The results of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/interventions for ongoing compliance.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions.

Findings include:

The facility's policy for food storage, dated January 1, 2026, revealed that all prepared items would be covered, labeled and dated clearly.

Observations in the main kitchen on June 8, 2026, at 9:13 a.m. revealed that a stand up fan had a build up of black dust and debris on the cage and was blowing towards the food prep area; and at 9:33 a.m. in the walk-in freezer located in the basement, there were 11 birthday gobs that were not dated.

Interviews with the Dietary Manager on June 8, 2026, at 9:13 a.m. and 9:33 a.m. confirmed that the dirty fan should not have been blowing towards the food prep area and needed cleaned, and the gobs should have been dated.

28 Pa. Code 211.6(f) Dietary Services.












 Plan of Correction - To be completed: 07/13/2026

The stand-up fan in the food preparation area was removed. The birthday gobs were discarded.

There were no other stand-up fans observed in the food preparation area. Walk-in freezers will be inspected for outdated food. Any food not labeled or dated will be discarded.

The facility policy for food storage will be reviewed and revised as necessary. Stand-up fans will not be utilized in food preparation areas. Walk-in freezer food items will be inspected for appropriately labeled and dated food according to the facility policy.

Dietary staff will be educated on Federal Regulation 812, the facility policy for food storage, and the importance of labeling and dating food items and not utilizing stand-up fans in the food preparation area.

Dietary Manager/designee will audit to observe properly dated food items within the walk-in freezers and the absence of fans within the food preparation area, daily for two weeks, weekly for two months, and monthly for two months. The results of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/interventions for ongoing compliance.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 56 residents reviewed (Resident 5) who had a feeding tube.

Findings include:

A facility policy for feeding tubes, dated January 1, 2026, indicated that feeding tube use occurs based on current clinical standards of practice with the intent to maintain the resident's nutrition and hydration status within acceptable parameter and decrease the risk of complications from use.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 20, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, and had a feeding tube.

Physician's orders for Resident 5, dated March 27, 2026, included orders for the resident to receive Novasource (a tube feeding formula) at 250 milliliters/hour as needed if the resident ate less than 50% for breakfast, lunch and dinner.

Review of Resident 5's meal intakes for March, April, May and June 2026 revealed that the resident did not eat breakfast on March 27; did not eat breakfast on March 28, 29, 30, 31, April 1, 2, 3, 5, 7, 8, 9, 11, 12, 13, 14, ate 1-25% of lunch on April 15; did not eat breakfast on April 16, 17, 18, 21, 23, 25, 29, 30, May 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 17, 18, 19, 21, 22, 23, 26, 27, 28; ate 1-25 % of lunch on May 29; did not eat breakfast on May 30, June 2, 4; did not eat dinner on June 5; did not eat breakfast on June 6; did not eat dinner on June 8; did not eat lunch on June 9, 10; and did not eat breakfast on June 11, 2026.

There was no documented evidence in the resident's clinical record that the resident refused or was offered the Novasource via feeding tube as ordered by the physician.

Interview with Registered Dietitians 1 and 2 on June 10, 2026, at 2:07 p.m. confirmed that there was no documentation that the resident refused or was offered the Novasource via feeding tube as ordered by the physician.

Interview with the Nursing Home Administrator on June 10, 2026, at 3:00 p.m. confirmed that there was no documentation that the resident refused or was offered the Novasource via feeding tube as ordered by the physician.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.












 Plan of Correction - To be completed: 07/13/2026

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, of professional malpractice or for purposes of any judicial or administrative proceeding.

Resident 5 was assessed by the Registered Dietitian on June 12, 2026 with no changes needed, as weight gain and improved meal intakes were identified. Resident 5's care plan was updated accordingly.

All residents with orders for supplements when meals are refused will be reviewed by the Registered Dietitian/designee for documentation of meal refusals and administration of supplements as ordered times one (x1), applicable corrections will be implemented as needed.

Licensed Nursing staff will be educated on the Enteral Feeding Tube policy and procedures by the Registered Nurse Instructors/designees. The education will include documentation of resident refusal of meals, documentation of offering supplements, and documentation of refusal, when applicable, of supplements.

The Registered Dietitian/designee will complete audits of documentation of resident receiving supplements as ordered after meal refusal daily for two weeks, weekly for two months, then monthly for two months. The results of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/interventions for ongoing compliance.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to administer a resident's continuous oxygen as ordered for one of 56 residents reviewed (Resident 174).

Findings include:

The facility's policy regarding oxygen therapy, dated January 1, 2026, indicated that supplemental oxygen therapy is provided and monitored for residents as per the provider's order, or in emergency situations, for the ease and comfort of respiratory effort and disease symptom management.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 174 dated June 4, 2026, indicated that the resident was cognitively intact, required supervision with daily care needs, received oxygen therapy, and had a diagnosis of chronic obstructive pulmonary disease (COPD- a disease that causes airflow blockage and breathing-related problems).

Physician's orders for Resident 174, dated May 28, 2026, included an order for the resident to receive continuous oxygen at a flow rate of 5 liters per minute (LPM) via nasal cannula (tubes that deliver oxygen into the nostrils) every shift.

Observations of Resident 174 on June 9, 2026, at 10:22 a.m. revealed that the resident was using his wheelchair to go back to his room from the dining room with an oxygen tank on the back of his wheelchair. The oxygen tank was set at 5 LPM and the tank was reading empty.

An interview with Registered Nurse 3 on June 8, 2026, at 12:41 p.m. confirmed that the resident's oxygen tank was empty.

Interview with the Nursing Home Administrator on June 8, 2026, at 3:00 p.m. confirmed that Resident 174's oxygen tank should have been checked and replaced.

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






 Plan of Correction - To be completed: 07/13/2026

Resident 174 was assessed for respiratory status and oxygen use, Medical Provider was updated and new orders were received on June 25, 2026, for supplemental oxygen to be used only overnight.

All residents using supplemental, portable oxygen will have their oxygen tanks reviewed by the Registered Nurse Supervisor/designee times one (x1), for quantity of oxygen remaining, tanks will be replaced as needed.

Nursing staff will be educated by the Registered Nurse Instructor/designee on the Bureau of Veterans Homes (BVH) Supplemental Oxygen Therapy protocol which includes the approximate time until the portable tank is empty based on the resident's ordered flow of oxygen.

Registered Nurse Supervisor/designee will audit quantity of oxygen remaining in portable oxygen tanks of five residents, daily for two weeks, weekly for two months, then monthly for two months. The results of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/interventions for ongoing compliance.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations: Based on a review of the facility policies, as well as observations and staff interviews, it was determined that the facility failed to label medications with the appropriate instructions for administration for two of 56 residents reviewed (Resident 66, 83). Findings include: The facility's policy regarding medication administration and labeling, dated January 1, 2026, indicated that it is the purpose to provide guidance regarding medication administration to be in accordance with good nursing principles and practices and only by people legally authorized to do so. Labels for individual drug containers must include directions for use. Only the container in which a prescription drug or device is sold or dispensed to the ultimate consumer shall bear a label which shall be written in ink, typed or computer generated and shall contain full directions for the use of its contents. Manufacturer's directions for the use of Jardiance (used to manage diabetes) dated April 2026, revealed that Jardiance should not be split, broken or crushed, this may affect the medications absorption and stability. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 66, dated March 23, 2026, revealed that the resident was cognitively impaired, was dependent on staff for all his daily care needs, and had diagnoses that included diabetes. Physician's orders for Resident 66, dated July 24, 2025 included an order for the resident to receive 25 milligrams (mg) of Jardiance once a day. Observations of medication administration for Resident 66 on June 10, 2026, at 09:15 a.m. revealed that Licensed Practical Nurse 4prepared the resident's medications, including Jardiance, by crushing it and then proceeded to administer the crushed medication to the resident. Interview with Licensed Practical Nurse 4 on June 10, 2026, at 11:20 a.m. revealed that she was unaware that she should not have crushed Jardiance, and that the medication package should have indicated "do not crush" if it was not supposed to be crushed and it did not. A quarterly MDS assessment for Resident 83, dated April 21, 2026, revealed that the resident was cognitively intact, required assistance with his daily care needs, and had diagnoses that included diabetes. Physician's orders for Resident 83, dated July 5, 2025, included an order for the resident to receive 10 mg Jardiance once a day. Observation of the West 2 medication cart June 10, 2026, at 11:20 a.m. revealed a medication card of 10 mg Jardiance for Resident 83. The medication card was not labeled with a "do not crush" label. Interview with Pharmacist 5 on June 11, 2026, at 2:08 p.m. confirmed that Jardiance should not be crushed and that that medication cards should contain a "do not crush " label to alert staff. Interview with the Nursing Home Administrator June 11, 2026, at 2:10 p.m. confirmed that the medication should not have been crushed and that medication cards should be labeled "do not crush" if the medication should not be crushed. 28 Pa. Code 211.9(a)(1) Pharmacy services
 Plan of Correction - To be completed: 07/13/2026

The medication cards for Jardiance for Resident 66 was labeled with a "do not crush" label. Resident 83 no longer resides at the facility.

Medications for residents will be reviewed by the Chief Pharmacist/designee to determine medications that cannot be crushed. The medication cards of medications that cannot be crushed will be audited to observed for the "do not crush" label. Any medication card identified without a "do not crush" label will have a label placed by the Chief Pharmacist/designee.

The Chief Pharmacist and pharmacy technicians will be educated the BVH Medication Labels policy and on "do not crush" labels on medications that cannot be crushed prior to delivery of the medication to the nursing unit. The education will be provided by the BVH Nurse Administrator/designee.

The Assistant Director of Nursing/designee will audit medication cards of three random medication cart weekly for two weeks then weekly for two months, then monthly for two months for the proper placement of the "do not crush" label on the medication cards. The results of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/interventions for ongoing compliance.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 Infection Control
The facility must establish and 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.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations: Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 56 residents reviewed (Resident 90). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. For Enhanced Barrier Precautions, signage should clearly indicate the high-contact resident care activities that require the use of gown and gloves, and PPE, including gowns and gloves, and should be available immediately outside of the resident room. The facility's policy regarding EBP, dated January 1, 2026, indicated that EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents, and an order for EBP will be obtained for residents with any of the following: Has a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDR. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Clear signage would be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. Gowns and gloves would be available immediately outside of the resident's room. A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 90, dated May 13, 2026, indicated that the resident was cognitively impaired, required assistance with care needs, had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), and had a diagnosis of neurogenic bladder (bladder lacks control due to nerve or muscle problems) and obstructive uropathy (blockage in the urinary system). Physician's orders for Resident 90, dated February 4 and April 28, 2026, included an order for the resident to have EBP and a urinary (foley) catheter (an indwelling catheter). A care plan for Resident 90, dated May 21, 2026, revealed that the resident had an indwelling foley catheter and staff were to use PPE for EBP that included gowns and gloves while providing close contact care. Observations on June 10, 2026, at 9:18 a.m. revealed that Resident 90 was in bed and the wash basin that his urinary catheter bag was in was tipped on it's side, causing the urinary catheter bag to be in contact with the floor. There was no sign posted outside the resident's room to indicate the resident was on EBP and there was no PPE available outside of the resident's room. At 9:24 a.m. Nurse Aide 7 repositioned the resident's catheter and did not use proper PPE. An interview with Nurse Aide 7 at that time revealed that she thought Resident 90 was not on EBP. An interview with Licensed Practical Nurse 8 on June 10, 2026, at 9:29 a.m. confirmed that Resident 90 was to be on EBP and that there was no sign posted or PPE available outside of his room. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
 Plan of Correction - To be completed: 07/13/2026

ResidentR90 had Enhanced Barrier Precaution (EBP) signage and Personal Protective Equipment (PPE) placed outside their room per policy.

All residents requiring EBP will be reviewed for proper EBP signage and PPE placement by the Infection Preventionist/designee times one (x1).

Nursing staff will be educated on the BVH Infection Control Precautions policy regarding EBP procedures including EBP signage placement and the usage of PPE related to EBP.

Infection Preventionist/designee will audit residents requiring EBP, to observe for proper EBP signage placement and PPE utilization by staff, daily for two weeks, weekly for two months, and monthly for two months. The results of the audits will be reviewed at the Quality Assurance and Performance Improvement meetings. The Quality Assurance Committee will determine the need for additional audits/interventions for ongoing compliance.


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