Health inspection·May 25, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, staff interview, and policy review, the facility failed to maintain infection prevention measures intended to help prevent transmission of disease and infections for 1 of 1 residents on isolation precautions. (Resident #146) Residents Affected - Few The findings include: On 5/23/23 at 2:11 PM, an observation was made of Staff A, a Certified Nurse Assistant (CNA), inside Resident #146's room under contact/enhanced barrier precautions. CNA A was observed providing incontinence care donning only gloves as personal protective equipment (PPE). On 5/23/23 at 5:11 PM, an observation was made of Staff B, a Registered Nurse (RN), and Staff C, a Licensed Practical Nurse (LPN), entering Resident #146's room. Staff B, RN, and Staff C, LPN, were observed touching Resident #146's pump used for intravenous antibiotics. Staff B, RN, and Staff C, LPN, were not observed washing their hands or donning any PPE. On 5/23/23, a review of medical records for Resident #146 was conducted and revealed a physician order for contact isolation from 5/22/23 through 5/29/23. Further review of the record revealed a positive laboratory test result dated 5/14/23 for Pseudomonas Aeruginosa (a bacteria that can cause infection in the blood, lungs and other parts of the body, and can spread in healthcare settings from one person to another through contaminated hands, equipment, or surfaces). The lab result stated Pseudomonas Aeruginosa is a multi-drug resistant organism: contact precautions indicated. On 5/22/23 at 8:35 AM, a progress note written by Staff D, another RN, stated all staff and residents were notified of barrier precautions due to MDRO (Multidrug-resistant organisms). A notice of contact precautions and required PPE use was posted on Resident #146's entrance. On 5/23/23 at 2:39 PM, an interview was conducted with Staff A, CNA. The surveyor asked if she was aware that this was a contact isolation room and she replied that she was not aware. Staff A further stated she was not aware she needed to use a gown to provide incontinence care and stated she had provided bowel care 3 times that day because Resident #146 had diarrhea. On 5/23/23 at 5:20 PM, an interview was conducted with Staff C, LPN. During the interview, it was revealed Staff C, LPN, was not aware Resident #146 was under precautions and stated if she would have known she would have wore a gown and gloves and performed hand washing before and after donning PPE. A review was conducted of facility's Categories of Transmission-Based Precautions policy, last revised October 2018, stated, Staff and visitors will wear gloves gloves (clean, non-sterile) when Page 1 of 3 106051 106051 05/25/2023 Coral Bay at Pensacola, LLC 600 W Gregory St Pensacola, FL 32502

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few entering the room. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. A review was conducted of the Guidelines for Prevention and Control of Infection Due to Antibiotic Resistant Organisms by the Florida Department of Health, Division of Disease Control and Health Protection Bureau of Epidemiology, updated December 2020. The guidelines revealed steps to prevent the spread of MDRO's include wearing gloves and a gown when treating patients. The guidelines furthe stated, During contact precautions, health care workers should wear a gown and gloves while in the patient's room, remove the gown and gloves before leaving the room, and perform hand hygiene when entering and leaving the room. During enhanced barrier precautions, health care workers should use personal protective equipment including a gown and gloves during resident care activities including changing briefs or assisting with toileting. A review was conducted of Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting published by the Centers for Disease Control and Prevention (CDC), last updated May 2022. On page 130, the guidelines listed Pseudomonas Aeruginosa as an infectious agent that is readily transmissible, have a proclivity toward causing outbreaks, may be associated with a severe outcome, and are difficult to treat. 106051 Page 2 of 3 106051 05/25/2023 Coral Bay at Pensacola, LLC 600 W Gregory St Pensacola, FL 32502

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and policy review, the facility failed to maintain a functional restroom emergency call system for resident use in 1 of 33 sampled resident rooms. (room [ROOM NUMBER]) Residents Affected - Few The findings include: Observations of the restroom emergency call system for room [ROOM NUMBER] were conducted on 5/23/23 at 12:40 PM and 5/24/23 at 3:17 PM. The call system did not function when the cord was pulled. During the observation on 5/24/23 at 3:17 PM, Employee E (Maintenance Assistant) attempted to initiate the call system. He stated the system did not have the proper cord and the system was not functional. Further interview was conducted with Employee E on 5/24/23 at 3:09 PM. Employee E stated they check random call lights in the facility twice a month and rely on nursing staff to let them know if a call light is not functional. Employee E was not able to produce documentation of when the call light for room [ROOM NUMBER] was last checked. Review of the facility policy for Answering the Call Light (revised March 2021) revealed the purpose of the procedure was to ensure timely responses to the resident's requests and needs. Number 4 stated, Be sure the call light is plugged in and functioning at all times. 106051 Page 3 of 3