Health inspection·September 10, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to implement Enhanced Barrier Precautions (EBP) as an infection control intervention designed to reduce transmission of organisms that employs targeted gown and glove use during high contact resident care activities for 1 of 1 residents observed for transmission based precautions. (Resident #131)The findings include: Observations performed on 09/07/25 at approximately 12:58 PM and 4:25 PM and 9/08/25 at 8:19 AM discovered that there was no EBP signage posted and no Personnel Protective Equipment (PPE) access outside of the room for Resident #131. (Photographic Evidence Obtained). On 09/07/25 at approximately 12:58 PM, an interview was conducted with Resident #131. She explained that she has been newly admitted to the facility status post colostomy and requires wound care to her surgical scar. On 09/08/25 at approximately 8:19 AM, an additional interview was conducted with Resident #131. She explained that the staff do not wear additional gowns or protective equipment during wound care. On 09/09/25 at approximately 11:25 AM, an interview was conducted with the Director of Nursing (DON) and the Infection Preventionist. They explained that Resident #131 was admitted with a small dehiscence to her surgical scar on 09/02/25. They further indicated that EBP was initiated in her care plan on 09/05/25, however they forgot to place the signage that includes instructions for use of specific PPE to be used and make PPE readily available near the entrance of the room for Resident #131. They acknowledged that between 09/05/25 and 09/08/25, EBP were not followed during high-contact resident care activities, providing opportunities for transfer of organisms.The physician's orders initiated on 09/03/25 for Resident #131 include cleanse area of dehiscence to proximal end of midline abdominal with wash, loosely pack wound with calcium alginate, cover with small foam dressing.The Care Plan initiated on 09/05/25 for Resident #131 has a focus for break in skin integrity with open area to proximal end of surgical wound, including a goal to minimize risk for symptoms of infection with an intervention that includes Enhanced Barrier Precautions. The weekly Wound Care progress note dated 09/09/25 reveals proximal end of midline abdominal surgical scar dehiscence present on admission. The Treatment Administration Record (TAR) for September 2005 reveals wound care to the proximal end of midline abdominal surgical scar dehiscence was provided on 09/03/25, 09/06/25 and 09/08/25.A facility policy titled Enhanced Barrier Precautions (EBP) (reviewed 07/03/25 and revised 08/19/25) states, EBP refers 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. Policy for use of EBP as an additional Multidrug-Resistant Organism (MDRO) mitigation strategy for residents that meet the following criteria, during high contact resident care activities. EBP are indicated for residents with the following wounds even if the resident is not known to be infected or colonized with a MDRO Wounds generally include chronic wounds that include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, wound care, skin opening requiring a dressing. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. The facility may choose to post Residents Affected - Few Page 1 of 2 106073 106073 09/10/2025 Life Care Center of Pensacola 3291 East Olive Rd Pensacola, FL 32514

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few signage on the door or wall outside of the resident room indicating the resident is on EBP. The facility should ensure PPE and alcohol-based hand rub are readily accessible to associates.A review of the Center for Disease Control and Prevention website at: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html#cdc_generic_section_2-enhanced-barrier-precau titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MRDO), dated 04/02/2024 was reviewed. It reveals that: when implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff awareness of the facility's expectations about hand hygiene and gown/gloves use, initial and refresher training, and access to appropriate supplies. To accomplish this, post clear signage on the door or wall outside of the resident room indicating the type of Precautions and indications for high contact resident care activities the use of gown and gloves; make PPE available immediately outside of the resident's door. 106073 Page 2 of 2