Health inspection·April 18, 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 ensure proper infection control practices while providing incontinence care and handling contaminated linens for 2 (R19 and R23) of 8 residents reviewed for incontinence and contact precautions. Residents Affected - Few Findings include: 1. R19's admission Record documented an admission date of 6/3/2021 and included diagnoses of methicillin staphylococcus aureus infections as the cause of the diseases classified elsewhere, osteomyelitis unspecified, vasculitis limited to the skin unspecified, and major depressive disorder, single episode, unspecified. R19's Quarterly Minimum Data Set (MDS) dated [DATE] documented R19 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R19 is cognitively intact. R19's MDS Section for Functional Abilities and Goals documented impairment under range of motion in her lower extremities on both sides. R19's MDS Section for Active Diagnoses documented R19 having an Infection of a Multidrug-Resistant Organism (MDRO). R19's Care Plan documented a focus area of R19 is at risk for a urinary tract infection related to history of urinary tract infection, indwelling catheter. On 4/15/2025 at 11:15 AM, R19's door was noted to have a red contact isolation sign that alerts staff and visitors of precautions and what personal protective equipment (PPE) to wear prior to entering the room, which included gloves, gown, mask, and shoe protectors. In the hallway outside of R19's door was a plastic bin with PPE supplies. On 04/15/25 at 11:40 AM, V3 (Resident Assistant/RA) entered R19's room to complete a bed linen change. V3 was changing R19's bed linen while wearing gloves, mask, and shoe covers. V3 did not wear a gown during bed linen change. On 04/17/25 at 10:57 AM, V3 (RA) stated, R19 does have contact isolation precautions in place. V3 stated she did enter R19's room to complete a bed linen change. V3 stated she entered R19's room with gloves, mask, and shoe covers on. V3 said there was no gown in the PPE bin outside the room for her to put on, but she should have worn a gown during contact with the bed linen change. On 04/17/25 at 10:30 AM, V4 (Infections Preventionist/IP) stated R19 currently has an active urinary tract infection with a culture result documenting a carbapenem-resistant enterobacterales (CRE). V4 stated R19 will maintain on contact precautions until she gets 3 negative UA's (urinalysis) each a Page 1 of 2 145386 145386 04/18/2025 Southgate Health Care Center 900 East Ninth Street Metropolis, IL 62960

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few week apart starting 48 hours after the last dose of antibiotic. V4 stated, R19 is under contact precautions with appropriate signage and supplies available. V4 stated, any staff member that encounters R19's bed linen should wear personal protective equipment that included gloves and a gown. R19's Urine Culture results dated 4/08/2025 documented a heavy growth of Providencia Stuart with a colony count >100,00 colony-forming units (CFU)/milliliters. The facility Infection Control Policy/Procedure for CRE (undated) documented under Policy, It is the policy of (name of facility) to use standard precautions/contact isolation precautions for residents who are known to be infected with an antibiotic resistive infection or staph infection. Under Procedure, Gown For Contact Isolation Precautions, gown for all direct contact with the patient or the environmental surfaces, including the patient sink which is potentially contaminated. 2. R23's admission Record documented an admission date of 1/2/2023 and included diagnoses of nontraumatic intracerebral hemorrhage unspecified, chronic viral hepatitis c, limitation of activities due to disability, and need for assistance with personal care. R23's Significant Change MDS dated [DATE] documented R23 has a BIMS score of 3, indicating R23 has severe cognitive impairment. R23's MDS Section for Functional Abilities and Goals also documented impairment under range of motion in her upper and lower extremities on both sides. Under Self-Care, R23's MDS documented dependent on staff care for toileting hygiene. R23's Care Plan documented a focus area of having a potential risk for urinary tract infection related to history of a urinary tract infection. On 04/17/25 at 09:23 AM, V2 (Certified Nurse Assistant/CNA) provided incontinence care to R23. V2 removed R23's soiled incontinence brief and had R23 turn on her right side. V2 then removed 4 wet wipes from R23's bedside table and laid them directly on R23's left bedside rail with no barrier. V2 then started to clean R23 with the wipes. On 04/17/25 at 10:30 AM, V4 (IP) stated, incontinence care items should have a barrier placed for supplies, including wipes. V4 stated the staff should not be directly lying incontinence wipes on a resident's bedside rail. On 04/17/25 at 10:34 AM, V2 (CNA) stated she did not follow the facility policy and procedure for providing incontinence care to R23 and should not have directly laid the wipes on R23's bedside rail. On 04/17/25 at 11:10 AM, V1 (Administrator) stated her expectations are for all facility staff to follow the infection prevention policy and procedures. The facility Perineal Care Policy and Procedure (reviewed 5/10/2024) documented under Purpose Staff at (name of facility) will ensure proper cleaning of the perineum to prevent infection and odor. 145386 Page 2 of 2