Health inspection·October 25, 2024

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 interview, observation, and record review, the facility failed to implement Enhanced Barrier Precautions per current standard of practice for 2 (R22 and R25) of 2 residents reviewed for infection control in the sample of 25 Residents Affected - Few Findings Included: 1. R25's admission Record documented an Initial admission Date of 8/28/2024. R25's admission Record also included diagnoses of retention of urine, unspecified, type 2 diabetes mellitus without complications, hypo-osmolality, and hyponatremia. R25's Physician Orders dated 10/1/24 documented a foley catheter in place. R25's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R25 was cognitively intact. On 10/22/2024 at 9:37 AM, prior to entering R25's room, there was no signage noted nor any Personal Protective Equipment (PPE) observed to be present or available by R25's room to indicate that enhanced barrier precautions were in place. On 10/22/2024 at 9:39AM, R25 sitting on her bed and appeared to have an indwelling catheter in place. R25 was alert and oriented and stated she had an indwelling catheter in place. R25's indwelling catheter bag was observed next to R25's bed. On 10/22/2024 at 12:26 PM, V5 (Registered Nurse/RN) stated that there is no resident on isolation or transmission-based precautions in the facility at this time. On 10/22/2024 at 1:29 PM, V3 (Certified Nurse Assistant/CNA) and V4 (CNA) gathered catheter care supplies for R25. During initial set up for R25's catheter care, V3 gathered a basin, towels, wash cloths, soap, trash bag and extra gloves. V3 and V4 did not wear a barrier gown during catheter care for R25. On 10/22/2024 at 1:32 PM, V3 and V4 both stated, there are no residents on isolation or transmission-based precautions in the facility. 2. R22's admission Record documented an Initial admission Date of 2/9/2024. R22's admission Record also included diagnoses of retention of urine, unspecified, chronic kidney disease, stage 3, unspecified and type 2 diabetes mellitus with diabetic neuropathy, unspecified. Page 1 of 2 145692 145692 10/25/2024 Axiom Healthcare of Flora 232 Given Street Flora, IL 62839

F 0880 R22's Physician Orders dated 9/20/24 documented a foley catheter in place. Level of Harm - Minimal harm or potential for actual harm R22's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R2 was cognitively intact. Residents Affected - Few On 10/22/2024 at 9:45 AM, prior to entering R22's room, there was no signage noted nor any PPE observed to be present or available by R22's room to indicate that enhanced barrier precautions were in place. On 10/22/2024 at 9:46 AM, R22 was lying in bed and had an indwelling catheter bag hanging on the side of her bed. R22 was alert and oriented and stated she had an indwelling catheter in place. On 10/22/2024 at 1:50 PM, V2 (Director of Nursing-DON/Registered Nurse-RN) stated, she was unaware of any enhanced barrier precautions policy or procedures, and she would need to reach out to (the) corporate office. On 10/22/24 at 2:22 PM, V2 stated she received the Enhanced Barrier Precautions (EBP) policy and procedure from the facility's corporate office. V2 stated the facility did not know about EBP prior to receiving the EBP policy today. On 10/24/2024 at 10:15 AM, V1 (Administrator) stated the facility had not been made aware of the Enhanced Barrier Precautions policy and procedure prior to 10/22/2024. On 10/22/2024 a Matrix for Providers (form CMS 802) was provided by the facility with two residents marked for indwelling catheters and no residents marked with transmission-based precautions. The facility policy titled Enhanced Barrier Precautions (undated) documents Enhance Barrier Precautions (EBP) should be used when contact precautions do not apply, for residents with any of the following: Open wounds that require a dressing change, indwelling medical devices and infection or colonized with a MDRO (Multidrug-Resistant Organisms). According to https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Under Implementation, the following is documented: When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove 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 required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. 145692 Page 2 of 2