Health inspection·November 21, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prevent the potential spread of infection by not ensuring Enhanced Barrier Precautions (EBP) were followed by not wearing personal protective equipment (PPE) for 1 of 5 residents reviewed for urinary catheter (#3), failed to identify the type of precaution staff needed to follow for EBP for 2 of 5 residents, (#3 and #12) and failed to follow manufacturer's guidelines for cleaning and disinfection of shared glucose meters for 1 of 5 residents reviewed for blood sugar monitoring (#11) of a total sample of 20 residents. Residents Affected - Some Findings: 1. On 11/19/2024 at 9:44 AM, resident #3 was resting in bed. Urinary catheter tubing was noted near the siderail of the resident's bed. Certified Nursing Assistant (CNA) E was in the room at the time and confirmed the resident had a urinary catheter. The resident's room door did not have any signage to indicate type of precautions or the required PPE that staff needed for residents with urinary catheters. On 11/19/2024 at 3:55 PM, resident #3 was observed lying in bed and had indwelling urinary catheter in place. Registered Nurse (RN) C and CNA B were in the room providing care to the resident. CNA B applied ointment to the resident's buttocks. RN C assisted CNA B to apply incontinence brief on the resident then applied moisturizing lotion to the resident's lower legs and feet. Neither CNA B nor RN C wore a PPE gown while they provided high contact care to the resident #3 with an indwelling foley catheter. On 11/19/2024 at approximately 4:50 PM, RN C acknowledged resident #3 did not have identification outside of her room to indicate the type of precautions or the required PPE needed for high-contact care for residents with indwelling catheter. RN C noted the resident had an indwelling urinary catheter and staff should have worn gowns to provide incontinence care. 2. On 11/21/2024 at 12:55 PM, resident #12 was observed sitting up in bed. He stated he had an indwelling urinary catheter. There was no signage outside the resident's room to indicate the type of precautions or the required PPE, and high-contact areas that required use of PPE. On 11/21/2024 at 4:50 PM, RN D verified resident #12 had an indwelling urinary catheter. She stated EBP should be used when providing high contact care. She confirmed there was no signage on the resident's room to alert staff of the type of precautions and PPE needed when providing high contact care to the resident. Review of the policy and procedure effective date: 09/01/2022 read that enhanced barrier precautions (EBP) are used to reduce the spread of multi-drug resistant organisms among residents by utilizing Page 1 of 2 105440 105440 11/21/2024 Aviata at Colonial Lakes 15204 W Colonial Dr Winter Garden, FL 34787

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gloves and gowns for high contact resident care activities. Residents who are appropriate for EBP include residents who have an indwelling medical device such as a urinary catheter. For those residents who have such indwelling medical devices like a foley catheter the procedure section notes to place an identification outside the resident room to include type of precaution, required personal protective equipment, and high-contact areas that require the use of personal protective equipment. High contact care activities, such as transferring, changing linens, incontinent care, provide an opportunity for transfer of multi-drug resistant organisms to staff hands and clothing. 3. On 11/19/2024 at 12:07 PM, Licensed Practical Nurse (LPN) A was observed as she checked resident #11's blood sugar with a glucometer. She said she used the same glucometer for 5 residents who needed blood sugar monitoring. LPN A completed the blood sugar monitoring, then returned to the cart to clean the glucose monitor. LPN A used a single use alcohol prep pad to wipe all the surfaces of the glucometer. She said she was supposed to wipe the glucometer with bleach wipes. She said there might be bleach wipes on other medication carts or they might be on back order. Review of resident #11's medical record revealed a physician order dated 05/10/2024 for Insulin Lispro with a sliding scale to be administered based on blood sugar taken prior to meals. Review of the glucometer's procedure guide section about cleaning and disinfecting the meter noted that to minimize the risk of transmitting blood borne pathogens, the cleaning and disinfecting procedure should be performed as recommended. to use specific disinfecting wipes, which did not include an alcohol prep pad, to wipe the entire surface of the meter. 105440 Page 2 of 2