Health inspection·March 13, 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 observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #32) reviewed for infection control. Residents Affected - Few LVN A failed to put on Personal Protective Equipment (PPE) while administering medication via feeding tube to Resident #32, who was on Enhanced Barrier Precaution (EBP). This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings included: Review of Resident#32's face sheet, dated 3/12/2025, revealed resident was an [AGE] year-old female admitted on [DATE] with diagnoses of spondylosis of cervical region (wear and tear of the spinal disks), chronic obstructive pulmonary disorder, gastrostomy status, and muscle weakness. Review of Resident#32's physician orders, dated 10/11/2024, revealed there was an order for Enhanced Barrier Precaution every shift due to feeding tube status. Review of Resident #32's care plan, dated 4/15/2024, showed that the resident was care planned for Enhanced barrier precaution. One of the interventions included gown and gloves should be worn when enteral feeding care occurs. Observation on 3/12/2025 at 08:24am, LVN A went in Resident#32's room to administer medication via enteral feeding tube without putting on a gown. She only put on gloves after performing hand hygiene. There was an EBP sign on Resident#32's door. In an interview on 3/12/2025 at 09:11am, LVN A stated that she forgot to put on a gown before administering medication for Resident#32. She stated the risk of not putting on personal protective equipment (PPE) was the spread of infection to staff and residents. In an interview on 3/13/2025 at 1:16pm, DON stated that staff should be mindful and look at their assigned residents for the day to determine which residents need EBP in order to adhere to it. She stated the risk of not following EBP was exposing self to different bodily fluids and infection. She stated since December, she has provided two in-service trainings on EBP. She stated she expected her staff to adhere to infection control policy and procedure. Page 1 of 2 455835 455835 03/13/2025 Interlochen Health and Rehabilitation Center 2645 West Randol Mill Rd Arlington, TX 76012

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of facility's Enhanced Barrier Precaution policy, dated 4/1/2024, revealed that Enhanced Barrier Precautions are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities . The policy also stated EBP should be implemented for procedures such as device care of use: central line, urinary catheter, feeding tube. Residents Affected - Few 455835 Page 2 of 2