Health inspection·May 30, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their infection control program as evidenced by failure to use Personal Protective Equipment (PPE) while providing care for 1 of 1 sampled residents on Enhanced Barrier Precautions (EBP) observed for catheter care, Resident #29. Residents Affected - Few The findings included: Review of the Centers for Disease Control and Prevention (CDC) guidance recommends wearing PPE for resident on EBP. The article titled Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) states, 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. The guidance can be found at: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html. Review of the policy titled Enhanced Barrier Precautions documented, 1. Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. 2. EBP employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity .3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene . f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) . Review of the record revealed Resident #29 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the current physician orders revealed Resident #29 had an indwelling urinary catheter and an order that stated, EBP-Enhanced Barrier Precautions due to Foley Catheter every day and night shift. Review of the care plan dated 05/02/25 documented, Resident is at risk for recurrent infection due to history of UTI/ESBL [Urinary Tract Infection / Extended-Spectrum Beta-Lactamase, bacteria that has developed resistance to many common antibiotics] in his urine. He has history of frequent straight catheter prior to admission and now has an indwelling catheter in place . Interventions / Tasks: Page 1 of 2 105828 105828 05/30/2025 Waters Edge Health and Rehabilitation 1500 SW Capri St Palm City, FL 34990

F 0880 Maintain EBP while providing care to catheter. Level of Harm - Minimal harm or potential for actual harm A catheter care observation was conducted on 05/29/25 at 9:20AM with Staff A, Certified Nursing Assistant (CNA). Upon entering the room, a sign titled Enhanced Barrier Precautions was observed on Resident #29's door. Staff A had a mask on and began the care by performing hand hygiene and donning gloves. Staff A was not observed putting on a gown. Staff A continued by prepping supplies, cleansing the tubing catheter, providing peri-care, and switching the regular urinary collection bag to a urinary leg bag. Hand hygiene was performed and new gloves were donned. Per Resident #29's request, Staff A adjusted the leg bag tighter to his leg. Staff A went outside of the resident's door (where the EBP gowns were located) and grabbed another box of gloves located right next to the hanging organizer of PPE. No gown was observed to be worn by Staff A. Residents Affected - Few Staff A continued to provide care to Resident #29 that consisted of: changing of briefs, dressing, grooming, bed bath, (ADL- Activites of Daily Living) care, and transferring the Resident from the bed to the wheelchair and then to the sink. This was all performed during approximately 45 minutes of direct care without the use of a gown. During an interview on 05/29/25 at 10:05 AM, when asked if she knew what the EBP sign at the resident's door means, Staff A stated, It means I have to wear a gown when providing care. When asked if there was a reason she didn't wear a gown, Staff A stated she forgot and should have worn it. Observation of the sign located outside Resident #29's doorway stated, Enhanced barrier precautions: . Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing / Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding, tracheostomy, and Wound care: any skin opening requiring a dressing. During an interview with Resident #29 on 05/29/25 at 11:42 AM, when asked if staff wear a gown when providing catheter care, he stated they typically wear it but sometimes they forget. An interview was conducted on 05/29/25 at 1:35 PM, the Infection Preventionist and the Director of Nursing (DON) were present, related to infection control findings. When asked who should be on EBP, the Infection Preventionist stated anyone who has an indwelling medical device, surgical wound, vascular wounds, wounds that are not fully closed, ostomies, gastrostomy tubes, or foleys (urinary catheters). When asked staff are expected to do with a residnet on EBP, the DON stated they should wear a gown and gloves during high touch care such as hands on ADL care and transfers. The Infection Preventionist and DON were informed a gown was not worn by Staff A during catheter care and the DON stated Staff A knows to wear it but was probably nervous. They both agreed with the findings. 105828 Page 2 of 2