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.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145692
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145692
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Axiom Healthcare of Flora
232 Given Street
Flora, IL 62839
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145692
If continuation sheet
Page 2 of 2
