Health inspection·June 19, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Resident #116 Residents Affected - Few An observation of Resident #116 was conducted on 6/16/25 at 1:18 PM. Contact precautions signage was observed to be on the resident's room door. (Photographic evidence was obtained.) The signage instructed everyone to clean their hands before entering the room, and providers and staff to put on gown and gloves before entering the room. Employee A (Laundry Aide) was observed to enter the room and deliver Resident #116's laundry. Employee A did not apply a gown or gloves prior to entering the room. Employee A was observed to touch Resident #116's bare hand with her bare hand and then left the room. An interview was conducted with Employee A on 6/16/25 at 2:30 PM. She stated she recalled touching Resident #116's hand when she delivered her laundry. She observed the signage on the door but she did not know she had to apply a gown and gloves before entering the room. She was not sure if she had training regarding isolation procedures. A review of Resident #116's electronic medical record revealed a physician's order dated 6/16/25 for contact isolation precautions every shift due to her urine testing positive with a multi-drug resistant organism. A review of the undated facility policy for Standard and Transmission-based Precautions revealed that contact precautions are implemented most often for residents who have an infection due to an epidemiologically important organism such as multi-drug resistant organism (MDRO). Staff are to put on gowns and gloves upon entry and remove gowns and gloves upon exit of the resident room. Based on observation, record review, staff interview, and policy review, the facility failed to ensure staff followed appropriate infection control practices during wound care for 1 of 1 resident sampled with a pressure ulcer (Resident #95) and 1 of 1 residents reviewed for contact isolation precautions (Resident #116). The findings include: Resident #95 A wound care observation was conducted concerning Resident #95 on 6/18/25 at approximately 8:50 AM. Staff B (Wound Care Nurse) put on gloves upon entering the resident's room. The nurse set up the wound care dressing supplies on the draped bedside table and repositioned the resident to her left side for access to the wound sites. It was observed that the resident's adult brief contained urine. The brief was rolled and tucked underneath the resident and the old dressings from resident's right Page 1 of 2 105727 105727 06/19/2025 Washington Rehabilitation and Nursing Center 879 Usery Road Chipley, FL 32428

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hip and coccyx pressure ulcer wounds were removed. At this point, wound care was performed, and new dressings were placed. At no time while performing the wound care was Staff B observed to perform hand hygiene and change her gloves. An interview was conducted with Staff B after this wound care was completed. She was asked about the infection control practice of changing gloves and if she should have changed her gloves before performing wound care and placing new dressings. She stated that Yes, I know that I know should have changed my gloves, I don't know how I missed that. An interview was conducted at approximately 9:05 AM with the Director of Nursing (DON). She was asked about her expectations regarding infection control practices for nurses when performing wound care and dressing changes. She stated that she expected that nurses will follow infection control practices and change their gloves as trained while performing wound care and dressing changes. The facility's undated wound care policy and procedure entitled Infection Control- Clean Dressing Change stated, 9. Position the resident for comfort 10. Perform hand hygiene 11. Put on clean gloves 12. Remove dressing and place in the resident's trash can 13. Remove gloves and perform hand hygiene. 14. Put on clean gloves. 15. Cleanse wound . 16.pat wound dry. 17. Remove gloves and perform hand hygiene. 18. Put on clean gloves. 19. Apply clean dressing as ordered and ensure dressing is dated. 105727 Page 2 of 2