Inspection·April 7, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's comprehensive care plan, dated 01/13/25, reflected Focus. [Resident #1] is on Enhanced Barrier Precautions. Goal. There will not be any transmission of infection from or to the resident. Intervention. Gloves and gown should be donned if any of the following activities are to occur .transfer, dressing .incontinent care, bed mobility, wound care . other high contact activity. Record review of Resident#1's Physician Orders Report, dated 11/05/24, reflected Enhanced Barrier Precaution related to foley Catheter and wounds. Wear gloves and gown for all catheter care and wound care. In an observation on 04/07/25 at 9:05 AM, Resident #1's room was noted with a sign on her door which indicated she was on Enhanced Barrier Precautions, no PPE cart in front of the room. LVN A entered Resident #1's room to do wound care. Resident #1's wound was in the sacral area. LVN A washed her hands and put on gloves, but no gown. CNA B entered Resident #1's room to help LVN A with wound care. CNA B washed her hands and put on gloves, but no gown. LVN A uncovered Resident #1 and unfastened Resident #1's brief. Both staff helped Resident #1 turn to her left side. LVN A opened Resident #1's brief, the resident had a bowel movement. LVN A removed the old dressing, and cleaned Resident #1's buttocks area, folded the brief, and pushed it under the resident. LVN A changed gloves without performing any kind of hand hygiene. LVN A cleaned Resident #1's wound, applied Santyl ointment, alginate calcium and border dressing on the wound. CNA B got a clean brief from the drawer and put it under the resident. Both staff turned Resident #1 on to her back, CNA B cleaned Resident #1's front area. Both staff turned Resident #1 to her right side. CNA B removed the dirty brief and finished putting the clean brief on the resident. LVN A washed hands and exited the room. LVN C entered Resident #1's room to help CNA B dress Resident #1 and get her ready for the mechanical lift, in anticipation of a dialysis appointment. LVN C washed hands, put on gloves, and no gown. Both staff got Resident #1 dressed in a T-Shirt and pants and put a sling under her. Both staff covered Resident #1, removed gloves, and washed hands before exiting the room . Interview with LVN A on 04/07/25 at 09:26 AM revealed she knew she was supposed to wear a gown for the resident's wound care, but she forgot. She stated she was nervous. LVN A stated she was trained to wear a gown for high contact with residents in Enhanced Barrier precautions. LVN A stated she was required to change gloves and perform hand hygiene whenever she was going from dirty to clean task. She stated she realized she had not done hands hygiene She stated the risk of not following the proper infection control policy, like not wearing proper PPE in EBP room, and performing hand hygiene was the spread of germs and infections. In an interview with CNA B on 04/07/25 at 09:28 AM, she stated she did not put on a gown, because there was no PPE supplies cart in front of the room, as the other rooms for EBP in the Hall. She stated she would put a PPE supply cart in front of the room. She stated the risk to residents was cross contamination. Interview with LVN C on 04/07/25 at 09:32 AM revealed she knew she supposed to wear a gown for any high contact with the residents on EBP, but she forgot. She stated she was in serviced on EBP, but she could not recall how long ago. She stated the risk to residents was cross contamination and development of infections. In an interview with the DON on 04/07/25 at 11:59 AM, she stated staff were taught any resident who was on Enhanced Barrier Precautions required gloves and a gown when providing any contact with the resident. The DON stated the staff were trained on when to change their gloves and sanitize their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455903 If continuation sheet Page 2 of 3 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 455903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Lodge Nursing & Rehabilitation 3800 Marina Dr Lake Worth, TX 76135 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hands. She stated staff needed to change their gloves when they went from dirty to clean. She stated the risk was an increased risk of infections. Record review of the facility's policy, dated 04/01/2024 and titled Enhanced Barrier Precaution, revealed Enhanced Barrier Precaution (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistance organisms that employ targeted gown and glove use during high contact resident care activities. Record review of the facility's policy, updated 03/2024 and titled Infection Control Policy & Procedure Manual 2019, , reflected 1. Hands hygiene. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene . After removing gloves . Gloves. Wearing gloves does not replace the need for hand washing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455903 If continuation sheet Page 3 of 3