Health inspection·July 15, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and State Surveyor asked LVN C how much oxygen Resident #1 was receiving. LVN C said Resident #1 was only receiving 1 1/2 LPM and it was supposed to be 2 LPM. LVN C asked Resident #1 who had changed her oxygen and Resident #1 said she did not know but it was supposed to be on 2 LPM. LVN C increased the oxygen to 2 LPM. State Surveyor asked LVN C to observe Resident #1's oxygen concentrator air intake area and LVN C said, It's pretty dirty. LVN C said she would get it took care of and cleaned.During an interview on 7/15/25 at 10:35 AM, LVN C said she had worked at the facility for approximately twelve years and normally worked on the day shift. LVN C said the night shift on Wednesdays were responsible for changing oxygen tubing, water bottles, nebulizers, and she would think they would also be responsible for cleaning the oxygen concentrator filters/air intake areas. LVN C said Resident #1's oxygen concentrator air intake area was pretty dirty. LVN C said if a resident was not receiving the physician's ordered amount of oxygen, it could decrease the resident's oxygen level. LVN C said she did check Resident #1's oxygen level this morning (7/15/25) and it was 97%, which was good. LVN C said it the oxygen concentrator had a dirty filter, or the air intake area was dirty, it could affect the resident's breathing and could contaminate the resident's airway and cause an infection. LVN C said it could also affect how the machine worked, and it could run hot.2. Record review of Resident #2's face sheet dated 7/14/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included quadriplegia (inability to move upper or lower body), shortness of breath, and lack of coordination.Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated he was unable to complete the BIMS score, which indicated he had cognitive impairment. The MDS indicated Resident #2 was dependent on staff for all ADLs. Record review of Resident #2's Care Plan dated 7/14/25 indicated he had a care area/problem of breathing patterns related to increased secretions with interventions including to suction as needed for increased secretions. During an observation on 7/15/25 at 5:48 AM, Resident #2 was asleep in bed and his oral suction catheter tubing was laid over the top of his night table and hanging in front of the night table with the mouth tip of the suction catheter touching the front of the nightstand table and it was not in a storage bag.During an observation on 7/15/25 at 10:40 AM, Resident #2 was asleep in bed and his oral suction catheter tubing continued to be laid over the top of his night table and hanging in front of the night table with the mouth tip of the suction catheter touching the front of the nightstand table and it was not in a storage bag.During an observation on 7/15/25 at 12:27 PM, Resident #2 was asleep in bed and his oral suction catheter tubing continued to be laid over the top of his night table and hanging in front of the night table with the mouth tip of the suction catheter touching the front of the nightstand table and it was not in a storage bag.During an observation on 7/15/25 at 2:07 PM, Resident #2 was awake in bed with head of bed elevated, he was non-verbal and only able to make slight hand gestures. Resident #2's oral suction catheter tubing continued to be laid over the top of his night table and hanging in front of the night table with the mouth tip of the suction catheter touching the front of the nightstand table and it was not in a storage bag.During an interview on 7/15/25 at 12:12 PM, LVN C said an oral suction catheter should be stored in a bag when not in use and should not be left out for bugs or anything to get on it. LVN C said the oral suction catheter should be changed out if it becomes dirty. LVN C said changing out all the oxygen, nebulizer, and suction equipment was scheduled on the Wednesday night shift and should be documented on the TAR. During an interview on 7/15/25 at 2:17 PM, the ADON said an oral suction catheter should be stored in a bag at the bedside when not in use. The ADON said the oral suction catheter was changed every Wednesday on the night shift and was scheduled on the MAR/TAR as a task to complete and document. The ADON said it would not be appropriate to hang the oral suction catheter over the nightstand, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675444 If continuation sheet Page 2 of 8 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 675444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reunion Plaza Senior Care and Rehabilitation Cente 1401 Hampton Rd Texarkana, TX 75503 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because it was gross and could spread infection. The ADON said the resident should receive the physician ordered amount of oxygen. The ADON said if a resident did not receive the ordered amount of oxygen, a resident could become hypoxic (not get enough oxygen to sustain bodily functions). The ADON said staff should be ensuring the resident was receiving the ordered amount of oxygen. The ADON said all respiratory equipment, oxygen tubing, humidifier water, nebulizers, and oral suction catheters, were changed every Wednesday on night shift. The ADON said the oxygen concentrator filters, and air intake areas should be cleaned also every Wednesday on the night shift. The ADON said if an oxygen concentrator filter or air intake area was not clean, a resident may not receive the proper amount of oxygen, and it was an infection control issue.During an interview on 7/15/25 at 2:45 PM, the DON said Resident #1 should receive the physician ordered amount of oxygen. The DON said the nurses should be checking the oxygen daily on each shift to ensure the resident was receiving the correct dosage. The DON said the department heads performed daily rounds to do room checks to check respiratory equipment to ensure tubing was dated timely and oxygen filters cleaned. The DON said staff should be changing the respiratory equipment and cleaning oxygen filters every Wednesday on the night shift. The DON observed the picture of Resident #1's oxygen air intake area. The DON said it was awful and did not look like it had been cleaned in a while. The DON said the Wednesday night nurses were responsible for changing all respiratory tubing and making sure it was dated. The DON said the oral suction catheter should be changed with the other respiratory stuff every Wednesday night. The DON said the oral suction catheter should be stored in a bag when it was not being used and should not be laid uncovered over the night table. The DON said a oral suction catheter could become infested with germs if it was not stored properly. The DON said if a resident was not receiving the physician ordered amount of oxygen, the resident could become oxygen deprived and lead to respiratory distress. The DON said a dirty oxygen concentrator filter or air intake area could lead to the resident not receiving enough oxygen or could also cause the machine to get hot and not work properly and could lead to respiratory decline.During an interview on 7/15/25 at 4:10 PM, the ADM said they have room round sheets, and each department head was given a set of rooms to inspect. The ADM said the room round sheets were turned into him and he should be notified in their morning meeting if there was an issue. The ADM said the department heads should be checking the oxygen concentrators to ensure the filters and air intake areas were clean and the respiratory equipment such as oxygen tubing, nebulizers, humidifier water, and oral suction catheters were changed and dated timely. The ADM said the nurses were responsible for the respiratory tubing labeling and bagging. The ADM said he would expect the oral suction catheter to be changed in a timely manner and dated, stored in a bag when not in use, and not laid across the nightstand. The ADM said a dirty air intake area could affect the air flow of the machine and not deliver the right amount of oxygen to the resident. The ADM said the oral suction catheter not being stored appropriately could make it hard to find and delay delivery of service to the resident. The ADM said the oral suction catheter should be stored in a bag to keep it clean and accessible.Review of the facility's policy titled Oxygen Therapy, Concentrator-Initiation dated revised January 12, 2020, indicated . the licensed staff would provide the prescribed amount of oxygen therapy to the residents as prescribed by the physician and according to practice guidelines . remove filter from the back of the machine weekly and rinse with tepid water . The policy did not address the cleaning of the oxygen concentrator air intake area.Review of the facility's policy titled Respiratory Equipment Change Schedule dated January 12, 2018, indicated . the community would provide a schedule for changing disposable equipment at regular intervals as determined by manufacturer recommendations and local community standards . oral suction catheter . change on an as needed basis . The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675444 If continuation sheet Page 3 of 8 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 675444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reunion Plaza Senior Care and Rehabilitation Cente 1401 Hampton Rd Texarkana, TX 75503 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 0695 policy did not address storage of the oral suction catheter. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675444 If continuation sheet Page 4 of 8 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 675444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reunion Plaza Senior Care and Rehabilitation Cente 1401 Hampton Rd Texarkana, TX 75503 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 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 9 residents (Residents #2 and Resident #3) reviewed for infection control practices.1. The facility failed to ensure CNA A and CNA B did not contaminate Resident #2's clothing, draw pad, bedding, pillows, and feeding tube pole after performing incontinent care.2. The facility failed to ensure CNA A and CNA B donned (put on) a gown while performing incontinent care on Resident #2, who was on Enhanced Barrier Precautions (EBP).3. The facility failed to ensure LVN C donned a gown while disconnecting Resident #3's feeding tube, assessing feeding tube placement, and attempting to flush the feeding tube, and the resident was on Enhanced Barrier Precautions.These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection.Findings included:1. Record review of Resident #2's face sheet dated 7/14/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #2 had diagnoses which included quadriplegia (inability to move upper or lower body), shortness of breath, and lack of coordination.Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated he was unable to complete the BIMS score, which indicated he had cognitive impairment. The MDS indicated Resident #2 was dependent on staff for all ADLs. The MDS indicated Resident #2 had a feeding tube.Record review of Resident #2's Care Plan dated 7/14/25 indicated he had a care area/problem of infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities, which included providing hygiene, changing briefs, and assisting with toileting.Record review of Resident #2's Physician Orders did not reflect an order for Enhanced Barrier Precautions.During an observation on 7/14/25 at 11:45 AM, Resident #2 was lying in bed with head of bed elevated with tube feeding being infused by an infusion device. There was a blue name tag on the outside of his room, a PPE cart and EBP sign just to the inside of his door in his room.During an observation on 7/14/25 beginning at 1:30 PM, CNA A and CNA B entered Resident #2's room and washed their hands and put on gloves. CNA A and CNA B positioned themselves on opposite sides of Resident #2's bed to perform incontinent care on Resident #2. CNA A pulled a male incontinent pad from between Resident #2's legs and placed it in the trash bag. CNA B was on the window side of Resident #2 and rolled resident toward her and held him on his side while CNA A cleansed the head of his penis with a wipe, then used another wipe to cleanse the shaft of the penis, then another 2 wipes to cleanse down each side of his inner thighs. CNA A then used the same gloves to reposition the resident's pillow, moved his feeding tube pole, placed one hand on his shoulder and one on his thigh and pulled him toward her without changing her gloves. CNA B then cleansed Resident #2's bottom with 3 wipes and went between his legs, there was no bowel movement present. Then CNA B and CNA A still wearing the same gloves used during incontinent care, repositioned Resident #2, stuffed a 3-sided body pillow all around Resident #2, used the draw pad under him to pull Resident #2 up in bed, pulled his gown down and then removed their gloves. Neither CNA A nor CNA B wore a gown during Resident #2's incontinent care. Resident #2 had a blue name tag outside his door, an EBP sign posted on the wall just inside his door along with a PPE cart with EBP supplies. During an interview on 7/14/25 at 1:50 PM, CNA A said she had worked at the facility since 2019 and normally worked the 6 AM to 2 PM shift. CNA A said staff should change gloves during incontinent care more times than she did on Resident #2. CNA A said she should have changed her gloves after cleaning Resident #2's front perineal (private) area and before touching multiple surfaces in his room. CNA A said it was a hygiene Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675444 If continuation sheet Page 5 of 8 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 675444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reunion Plaza Senior Care and Rehabilitation Cente 1401 Hampton Rd Texarkana, TX 75503 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 - Some thing and cross-contamination and could give Resident #2 an infection. CNA A said it was an infection control issue and could cause skin irritation too. CNA A said she would know someone was on EBP if there was a bucket and a sign outside the resident's door. CNA A said staff had to suit up with gown, gloves, and mask if a resident was on EBP. CNA A said residents on EBP were the residents with something in their urine or bowel. CNA A said Resident #2 probably should be on EBP because he had a feeding tube. CNA A said she did not see the EBP sign or the bucket just inside Resident #2's room and did not know what EBP was. CNA A said she did not know why Resident #2 had a EBP sign and cart, because they did not use it. CNA A said she had been on Resident #2's hall since April 2025 and had not ever used a gown during Resident #2's care.During an interview on 7/14/25 at 1:56 PM, CNA B said she had worked at the facility since May of 2025 and normally worked the 2 PM -10 PM shift but picked up a 6 AM -2 PM on 7/14/25. CNA B said she should have changed her gloves after performing incontinent care on Resident #2 and before touching multiple surfaces in his room. CNA B said it was cross-contamination and could cause him an infection. CNA B said they should have worn gowns while performing incontinent care on Resident #2 because he had a feeding tube. CNA B said EBP was to protect the staff and the resident from cross-contamination. CNA B said not wearing a gown during incontinent care could spread infection. CNA B said she did not see the EBP cart or EBP sign that was just inside Resident #2's room.Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA A dated 5/21/25 had a check mark in the met column which indicated CNA A had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. Record review of the facility's Nursing Services-Competency Evaluation for Skill/Procedure: Perineal Care without catheter of CNA B dated 5/30/25 had a check mark in the met column which indicated CNA B had performed the procedure of perineal care and met the performance criteria, which included discarding used supplies, removed gloves, and performed hand hygiene and applied new gloves and placed new brief and changed lines as needed and positioned resident comfortably, and gave table and call light. 2. Record review of Resident #3's face sheet dated 7/15/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #3 had diagnoses which included myotonic muscular dystrophy (genetic condition characterized by progressive muscle weakness and wasting), diabetes (high blood sugar), and gastrostomy (feeding tube).Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated she had a BIMS of 10, which indicated she had moderate cognitive impairment. The MDS indicated Resident #3 required moderate to dependent on staff for most ADLs. The MDS indicated Resident #3 had a feeding tube.Record review of Resident #3's Care Plan dated 7/15/25 indicated she had a care area/problem of altered nutritional status: enteral feeding monitor. Resident #3 also had a care area/problem of Infection control with intervention of Enhanced Barrier Precautions, gown and glove use during high-contact resident care activities.Record review of Resident #3's Physician Orders dated 7/01/25 - 7/31/25 did not reveal an order for Enhanced Barrier Precautions.Record review of Resident #3's Medication Record dated 6/23/25 7/15/25 indicated Enhanced Barrier Precautions every shift.During an observation and interview on 7/15/25 at 9:53 AM, Resident #3 was lying in bed and had a feeding tube infusion device connected to her feeding tube and the alarm was going off that it had completed. Resident #3 said staff wear gloves when administering her feedings and medications through her feeding tube and when providing incontinent care, but the staff never wear gowns during her care. There was a blue name tag outside her door, a PPE cart just inside Resident #3's door, but there was no EBP sign posted.During an observation and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675444 If continuation sheet Page 6 of 8 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 675444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reunion Plaza Senior Care and Rehabilitation Cente 1401 Hampton Rd Texarkana, TX 75503 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 - Some interview on 7/15/25 beginning at 10:04 AM, LVN C entered Resident #3's room and put on gloves. LVN C then pulled back the Resident #3's covers to expose her feeding tube. LVN C unhooked the feeding tube, then placed her stethoscope on the resident's abdomen, and checked placement of the feeding tube with 60 cc of air. LVN C then attempted to flush the feeding tube with water and then begun rolling the feeding tube between her fingers as she was leaned against the resident's bed/bedding. LVN C did not wear a gown as part of EBP. LVN C said they often had difficulty flushing the resident's feeding tube. LVN C said she was going to have someone else come try to flush it. During an interview on 7/15/25 at 10:35 AM, LVN C said she had worked at the facility for approximately twelve years and normally worked on the day shift. LVN C said she would know a resident was on EBP because they should have a PPE box in their room. LVN C said the EBP was for residents that had urinary catheters, wounds, feeding tubes, or any openings that could introduce infection. LVN C said residents on EBP should also have a sign posted indicating they were on EBP. LVN C said if staff were in direct contact with the resident, they should suit up and I did not do it on Resident #3. LVN C said she should have also worn a gown with her gloves during Resident #3's care. LVN C said it was important to follow EBP due to the at-risk residents had ports of entry for infection and EBP protected both the resident and staff. LVN C said EBPs was so staff did not carry anything from one resident to another resident. LVN C said if staff did not follow the EBP, it could place the residents at a higher risk of infection.During an interview on 7/15/25 at 2:17 PM, the ADON said he was also the Infection Preventionist. The ADON said staff should change their gloves during incontinent care any time they were doing different tasks. The ADON said the staff should have changed their gloves and performed hand hygiene after cleaning the Resident #2's front perineal area and prior to touching any other surfaces in the resident's room. The ADON said then staff should have changed gloves and performed hand hygiene after cleaning the resident's back perineal area and prior to touching any other of the resident's surfaces to prevent cross-contamination. The ADON said it was important to perform hand hygiene and change gloves appropriately to prevent cross-contamination and prevent the spread of infection. The ADON said all staff were responsible for ensuring staff were following the infection control policy and procedures. The ADON said residents who were on EBP was indicated by the blue name tags outside the resident's door and a PPE cart inside the resident's room. The ADON said they do not use the EBP signs, but staff had been educated that the blue name tags were indicative of the resident being on EBP. The ADON said any resident who had an invasive device, such as urinary catheter, a feeding tube, dialysis access, wounds or anything that would increase the risk of infections from an outside source would be on EBP. The ADON said the purpose of EBP was to protect the resident from an outside source of infection from direct care contact. The ADON said the resident, who was on EBP, was at an increased risk of infection if staff did not wear gown and gloves during direct care. The ADON said staff could spread infection from one resident to another resident if they were not wearing a gown during direct care. During an interview on 7/15/25 at 2:45 PM, the DON said staff should know a resident was on EBP from the blue name tags outside the resident's door and a PPE cart inside the resident's room. The DON said they do not use the EBP signs and only used the blue name tags outside the resident's room. The DON said the reasons a resident would be on EBP would be anyone with a feeding tube, urinary catheter, wounds, and any other indwelling device. The DON said the purpose of EBP was almost a reversed precaution, to protect the resident from getting something from the staff due to the resident was at a higher risk of infection and cross-contamination. The DON said staff should have changed their gloves when going from a dirty surface to a clean surface. The DON said staff should wash or sanitize their hands prior to and post incontinent care. The DON said the Infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675444 If continuation sheet Page 7 of 8 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 675444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Reunion Plaza Senior Care and Rehabilitation Cente 1401 Hampton Rd Texarkana, TX 75503 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Preventionist and herself would be responsible for ensuring staff were following the infection control policy and procedures. The DON said staff could transfer any bad bugs anywhere they touched with their contaminated gloves. The DON said the resident had the potential of infection if staff were not following EBP and transferred germs or bacteria from one resident to another resident. During an interview on 7/15/25 at 4:10 PM, the ADM said he would expect staff to follow the facility's infection control policy and procedures and change gloves and perform hand hygiene per their policies. The ADM said he would expect the EBP to be followed to protect the residents from anything staff may have come in to contact with. The ADM said not changing gloves, performing hand hygiene, following the EBP could be a potential infection control issue.Requested an Infection Control policy on 7/15/25 at 5:00 PM from the facility's Regional Nurse and was provided a policy titled Infection Prevention, Control & Surveillance, which did not contain pertinent information. Record review of the facility's policy titled Perineal Care dated revised April 10, 2023 indicated . staff would provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection . procedure . perform hand hygiene. Apply clean gloves . 5. Perineal care for a male resident . d. wash tip of penis . f. cleanse the shaft of the penis . 6. observe perineal area . 8. Turn resident to clean all areas of buttocks . 9. Dispose of gloves and used supplies and perform hand hygiene . 10. Apply new gloves and place new brief . 11. Position resident comfortably . Record review of the facility's policy titled Hand Hygiene for Staff and Residents dated revised February 2025 indicated . purpose . to reduce the spread of infection with proper hand hygiene . hand hygiene was the most important component for preventing the spread of infection . hand hygiene was done . before . before resident contact . after . contact with soiled or contaminated articles, such as articles that were contaminated with body fluids . resident contact . contact with contaminated object or source where there was a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds . toileting or assisting others with toileting .Record review of the facility's policy titled Enhanced Barrier Precautions dated revised March 2025 indicated . many residents in nursing homes were at increased risk of becoming colonized and developing infections with multi-drug-resistant organisms (MDROs) . facility utilized Enhanced Barrier Precautions (EBP) as a strategy to decrease transmission of CDC-targeted and epidemiologically important MDROs when Contact Precautions do not apply . indications . wounds and/or indwelling medical devices . indwelling medical devices include central lines . urinary catheters, feeding tubes . high contact resident care activities . providing hygiene . changing briefs or assisting with toileting . device care or use . feeding tube . communication . indicate the residents who were on EBP by subtle means, such as an alternate color of the resident's name badge on door . Event ID: Facility ID: 675444 If continuation sheet Page 8 of 8