Health inspection·November 26, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many returned or what happened with them. CK A stated the stand alone reach in refrigerator was used to store food items such as egg products, sausage, bacon, beef broth etc . She stated she was not able to identify the yellow substance that crusted over the bottom of the fridge but stated it was supposed to be cleaned and it was the expectation that dietary staff cleaned it once a week. CK A stated if items were not labeled with a use by date then staff would not know when they become expired. She stated dented cans could leak and rust or if dented enough to where punctured, it could introduce bacteria to the food which would make residents sick. CK A stated not keeping the kitchen refrigerator sanitized such could cause contamination of food products.In an interview and observation on 09/23/25 at 09:43 AM with the DM, he stated there was a dented can section and it was his expectation dented cans were removed from regular use cans and be placed there so they could be returned when the food truck arrived. The DM was observed removing the dented cans and clearing space on a small black cart outside of the can storage room to place the cans, an observation of the cart did not reveal clear identification which indicated it was for dented cans identifying it as a place staff would place them. The DM also tried to make audits of the kitchen weekly to identify expired items. He stated the bread should not be used if it looked spoiled. The DM stated the 09/02/25 marked on the box of sweet potatoes was the received date, but stated they would be thrown away, because they did not appear good. The DM stated it was his expectation items in the refrigerator were marked with an open or pulled date and use by date. The DM stated sanitation of the kitchen and appliances, microwaves, and refrigerator was to occur daily and every shift by the dietary staff. He stated failure to keep the kitchen and food areas clean could cause cross contamination, he stated expired items could make residents sick, and dented cans could have bacterial growth . In a follow up observation on 09/23/25 at 11:44 AM, CK B was observed preparing desserts and moved over next to the steamtable and assisted with the plating and preparation of the meal trays. CK B was observed with a hairnet but no beard guard. CK B had a beard approximately a quarter inch long. In an interview on 09/23/25 at 12:54 PM with CK B, he stated it was the facility's expectation that dietary staff were to always wear hairnets while in the kitchen and a beard guard if they had a beard. He stated a negative outcome of not wearing a beard guard would be hair could fall in the food. He stated normally the hairnets were stocked on the kitchen window shelf (window from dining room to kitchen) but there were not there and were not readily available, so he forgot to put one on. CK B stated dietary staff or the DM would refill them if not stocked. In an interview 09/23/25 at 12:58 PM with the DM, he stated it was his expectation all dietary staff wore hairnets and beard guards prior to entering the kitchen. He stated those were items that should always be stocked outside of the kitchen and made available and a negative outcome of not wearing them would be hair can contaminate food or drinks . In a follow up observation of the kitchen on 09/24/25 at 09:21 AM, revealed four of the 12-count bags of hot dog buns on the bread rack with the best by date of 09/09/25 were still on the rack next to fresh bread that had been stocked. The bread now 15 days past its best by date felt hard and stale with freshness noticeably affected. In an interview on 09/24/25 at 09:30 AM with the DM over the observed bread still on the bread rack for use 15 days past its best by date which was brought to his attention 09/23/25, he stated he had a conversation with the facility dietician (DTN) and was told by her the best by date was different than an expiration date and it was up to the facility when they wanted to throw it away. The State Surveyor asked the DM if DTN was advised the bread was hard and quality affected to which the DM responded, I'm just passing along what I was told. The bread remained on the bread rack for use and the DM walked away . In an interview on 09/24/25 at 10:10 AM with the DTN, she stated it was her expectation the food served to residents was nutritious, delicious, and provide the appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many amount of carbs , fats, and proteins. The DTN stated bread should not be kept much longer past its best by date and probably no more than a week. The DTN stated she would hate for residents to receive stale bread. The DTN stated dietary staff should pay attention to color, texture, and smell. She said, if it feels stale or has anything growing on it, it should be discarded. The DTN stated it was her expectation that hairnets and beard guards were always worn in the kitchen and there was no exception. The DTN stated it was her expectation food working areas were maintained clean and if the refrigerator had visible gunk it needed to be cleaned. The DTN stated chicken pulled from the freezer to the refrigerator to thaw should have a received date and a pulled date and staff would need to know how long it had been sitting there to thaw. She stated all other food items needed to have a received date, opened date, and use by date. The DTN stated items should be used on first in, first out basis and there should not be any expired items. She stated it was her expectation dented cans had a designated area and were pulled not to be used and kept in the separate marked area until they could be returned, and the facility reimbursed for them. The DTN stated she did not recall having the conversation with the DM about keeping the bread that was 15 days past its best by date. In an interview on 09/25/25 at 03:02 PM with the ADM, he stated it was his expectation dietary staff wore hairnets and beard guards, and refrigerators and equipment were cleaned daily and as mess is made. The ADM stated dented cans should be separated out and returned to the vendor. He stated food items should be labeled and dated, and should contain a date it was opened, what it was, and the date it expired or used by. The ADM stated it was his expectation dietary staff checked daily for expired foods and they should be discarded. The ADM stated his expectation for resident meals was it should taste good, be delicious and high quality. He stated with bread he would check if it was moldy or looked or felt bad and make sure it was fresh before use. The ADM stated a negative outcome of not wearing hairnets would be hair could get in the food, not labeling and dating items could potentially result in expired food being used, and using expired food could result in poor taste.Record review of the facility matrix, dated 09/23/25, reflected no residents were on tube feeding, and full census had the potential to be affected by these failures in 1 of 1 kitchen. Record review of the facility's Equipment Sanitation policy Dietary Services Policy and Procedure Manual 2012 reflected: We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner.Large equipment is to be sanitized by spraying or wiping with a chemical sanitizing solution at least twice the minimum strength of solutions needed for immersion sanitizing. Record review of the facility's Food Safety policy Dietary Services Policy and Procedure Manual 2012 reflected: We will ensure all food purchased shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food shall be handled in a safe manner.- Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly. Perishable opened foods shall be used within 7 days or less, in compliance with the Texas Food Establishment rules. Non-perishable foods will be used if the quality of the product is maintained. Dented or otherwise damaged cans will not be used, unless inspected by the dietary service manager and found not to be dented on the top or seam and not perforated. - Dented cans will be stored in a separate location and returned to the food vendor for credit.Record review of the facility's Food Storage and Supplies- Dry Storage and Supplies policy Dietary Services Policy and Procedure Manual 2012 reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects.- Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.- When items are received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it, so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the item should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes.- On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Spoiled foods will develop an off odor, flavor or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten. There are two types of bacteria that can be found on food: pathogenic bacteria, which cause foodborne illness, and spoilage bacteria, which causes foods to deteriorate and develop unpleasant characteristics such as an undesirable taste or odor making the food not wholesome, but do not cause illness. Perishable foods have been processed/treated and sealed to eliminate pathogenic bacteria, but spoilage bacteria can multiply, and this is what causes the food to deteriorate in quality and taste. If perishable food items are not stored at the proper temperature, spoilage bacteria can grow faster than anticipated and food becomes spoiled and should not be served. Food items such as loaves of bread or dairy products with a stamped best-by or use by date do not need to be labeled when opened as this will not affect the date by which they should be used. However, if possible, food spoilage is observed prior to the best by date, the product will be discarded. - Frozen items that should be thawed before preparation should be stored under refrigeration until thawed and should be dated with the date removed from the freezer and used within 7 days.Record review of the facility Fundamentals of Infection Control Precautions not dated reflected: A variety of infection control measures are used for decreasing the risk of transmission of microorganisms inthe facility. These measures make up the fundamentals of infection control precautions.- Dietary staff will wear hair restraints (e.g., hairnet, hat, and/or beard restraint) while in the kitchen areas to prevent their hair from contacting exposed food.Record review of the 2022 U.S. Food and Drug Administration Food Code reflected:3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.(B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete combinations specified in (A) of this section and: if (1) The day the original container is opened in the food establishment shall be counted as Day 1; Of and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (2) Is in a container or package that does not bear a date or day; or 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. food shall be protected from cross contamination by:(4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings. Event ID: Facility ID: 676117 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 4 of 7 residents (Resident #7, Resident #23, Resident #18, and Resident 11) reviewed for infection control. 1. The facility failed to follow hand hygiene procedure during direct care for Resident #7, Resident #18, and Resident #23.2. The facility failed to post a sign on Resident #11's door to inform nursing staff about Enhanced Barrier Precautions with readily available personal protective supplies before wound care provided. These failures could place residents at risk for infection transmission, sepsis, and hospitalization.Findings include:1.Record review of Resident #18's face sheet, dated 09/24/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included parkinsonism (a group of neurological disorders that share similar symptoms to Parkinson's disease like involuntary shaking movements and stiffness in the muscles), bone density disorder, chronic atrial fibrillation (type of heart abnormal rhythm), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest).Record review of Resident #18's Quarterly MDS assessment, dated 08/20/25, reflected a BIMS score 99, which indicated Resident #18 was not able to complete the interview. Resident #18 was totally dependent on staff for maintaining toileting hygiene.Record review of Resident #18's Care Plan, dated 05/28/25, reflectedResident #18 had Self Care Performance Deficit and had bladder and bowl incontinence with risk for UTIs.Observation on 09/24/25 at 12:31 PM revealed CNA D did not sanitize her hands between changing gloves and did not change gloves between front/back peri-areas of Resident #18. CNA D touched the package with wipes with contaminated gloves 7 times before changing gloves.Interview on 09/24/25 at 12:51 PM with CNA D revealed she had hand hygiene and peri-care training provided monthly. CNA D stated she needed to sanitize her hands every time she changed gloves and between cleaning the front/back peri areas. She stated that she forgot to sanitize her hands and change gloves. She stated that residents can get infection and sick.2. Interview on 09/24/25 at 01:52 PM, CNA C stated she was trained on hand hygiene and peri-care last week. She stated she should remove gloves after completing peri-care and wash hands before touching anything else in the resident's environment. She stated not cleaning her hands and not changing gloves would spread infection to other residents. Record review of Resident #23's face sheet, dated 09/24/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that causes memory loss, cognitive decline, and changes in behavior and personality), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels) and muscle weakness. Record review of Resident #23's Quarterly MDS assessment, dated 07/011/25, reflected a BIMS Score of 9, which reflected moderate cognitive impairment. Record review of Resident #23's Care Plan, dated 07/08/25, reflected: [Resident #23] had bladder and bowel incontinence and required nursing staff provide peri-care after each incontinent episode. Observation on 09/24/2025 at 1:41 PM of peri-care for Resident #23 revealed CNA C did not sanitize her hands or change gloves between cleaning the front and back peri areas. She did not remove contaminated gloves after completing peri-care. CNA C assisted Resident #23 to transfer back to her wheelchair and took her in the wheelchair to the hallway while touching the doorknob handle. 3. Record review of Resident #7's face sheet, dated 09/24/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 included dementia (a progressive and irreversible brain disorder that causes memory loss, cognitive decline, and changes in behavior and personality), muscle weakness, and Down syndrome (a genetic disorder caused by the presence of an extra copy of chromosome 21. This additional chromosome leads to characteristic physical features, intellectual disabilities, and developmental delays). Record review of Resident #7's Care Plan, dated 04/15/25, reflected [Resident #7] had bladder and bowel incontinence and required nursing staff provide peri-care and apply barrier creams after every incontinent episode. An observation on 09/24/25 at 03:54 PM of peri-care for Resident #7 revealed CNA E and CNA F cleaned her peri-area and changed gloves without conducting hand hygiene. CNA E did not remove gloves before reaching for the side table and opening a drawer. She took out a barrier cream and applied cream on Resident's #7 skin. Interview on 09/24/25 at 04:05 PM, CNA E and CNA F stated they were trained on hand hygiene, and they were supposed to wash their hands between glove changes and not touch furniture with contaminated gloves. CNAs E and F stated they were supposed to change gloves and conduct hand hygiene between front and back peri-care areas and if gloves become soiled. CNA E stated she forgot to change gloves and performed hand hygiene as being nervous. She stated. They stated that not performing hand hygiene and changing gloves can make residents sicker.4. Observation of Resident #11's room did not show any EBP signage on his door and no PPE available near his room. Wound care was provided to him on the day before the survey and was not observed. Record review of Resident #11's Care Plan, dated 06/19/2025, reflectedResident #11 had a surgical site to the back. Resident #11 was on enhanced barrier precautions and gloves/gown should be applied when wound care was performed.Record review of Resident #11's active orders, dated 06/19/2025, reflected Clean surgical wound to Left ribs with wound cleanser, pat dry, apply appropriate size of Prisma to wound and cover with secondary dressing melgisofbplus calcium alginate 4x4 in cover with mepilex border 2xper week. Record review of Resident #11's Quarterly MDS assessment, dated 09/01/2025, reflected a BIMS Score of 99, which indicated the resident was not able to complete the interview. Resident #11's assessment revealed he had a surgical wound and surgical wound care with application of non-surgical dressing.Record review of Resident #11's face sheet, dated 09/24/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia (a progressive and irreversible brain disorder that causes memory loss, cognitive decline, and changes in behavior and personality), anemia (a condition in which there is a lower-than-normal amount of red blood cells), hypertension (a chronic medical condition characterized by persistently elevated blood pressure), and emphysema (a chronic lung disease that damages the small air sacs [alveoli) in the lungs).An interview on 09/25/25 at 3:40 PM with the DON, who stated she was responsible for ensuring staff conducted proper hand hygiene/following infection control measures when providing care for the residents. She stated she conducted weekly routine checks and in-services. She stated the policy on hand hygiene, providing peri-care, wound care, and foley catheter care was to conduct hand hygiene before going in the room, between changing gloves and front/back peri-cares and when coming out of the room. The DON stated the last training on infection control and hand hygiene was conducted yesterday (09/24/2025) and during annual skills training sessions, weekly audits, and in huddles. The DON stated a potential negative outcome for the residents would be the transmission of bacteria.An interview on 09/26/2025 at 9:21 AM with the DON revealed Resident #11 had orders for enhanced barrier precautions for his wound care. She stated Resident #11 used to have a sign on his door, and she did not know what had happened to it. She also was not sure what happened to the box with personal protective equipment which included gowns and gloves outside Resident 11's door. She stated charge nurses provided wound care to Resident #11 once a week to use personal protective equipment available on the treatment cart. She stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676117 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 676117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605 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 if not followed enhanced barrier precautions the multidrug resistant organisms could be transmitted to this resident and other residents in the facility.Interview on 09/25/2025 at 4:35 PM with the ADON, who stated Resident #11 was supposed to be on enhanced barrier precautions and his room should be marked with a sign notifying staff regarding his precautions. She stated nursing staff were supposed to wear gloves and gowns during wound care. She stated personal protective equipment which included gowns and gloves was available on the treatment carts. She stated the potential negative outcome of not following enhanced barrier precautions would be spreading multi-drug resistance bacterial infection to the residents. She stated staff were trained in proper techniques of hand hygiene and peri-care monthly and as needed. She stated a potential negative outcome to the residents would be cross contamination. Interview on 09/25/2025 at 12:35 PM with the ADM, who stated hand hygiene and wearing/changing gloves was one of the most important requirements for staff in the facility to prevent the risk of infection. He stated nursing staff, which included himself, received in-services on hand hygiene policy. Record review of Infection Control Policy & Procedure Manual, dated 03/23, reflected: The fundamental of infection control precautions is hand hygiene before and after direct resident contact, before and after assisting a resident with personal care, before and after changing a dressing, after removing gloves, after handling soiled equipment. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities including unhealed surgical wounds. The facility will ensure personal protective equipment and alcohol-based hand rub are readily accessible to staff prior to entry to their room.Record review of In-Service training for Enhanced Barrier Precautions dated 6/3/2024, 8/21/2024.2/6/2025, 4/16/2025 reflected There will be a sign posted outside of the room. It will tell staff when to wear gowns and gloves to assist the resident. Outside of the room there will be the gown and gloves they need to wear before entering the room. Staff should remove gown contaminated gown and gloves before leaving the room.Record review of the facility undated, Hand Hygiene/Handwashing Policy and Procedure reflected, reflected Hand hygiene/handwashing is the most important component for preventing the spread of infection. Maintaining clean hands is important for patients, residents and visitors as well as staff.1. To provide protective barriers and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin.2. To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures that involve touching a residents' mucous membrane and nonintact skin.3. To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident, or a fomite can transmit these microorganisms to another resident; in this situation, gloves must be changed between resident contacts, and hands washed after gloves are removed know due not being involved in clinical side. Event ID: Facility ID: 676117 If continuation sheet Page 8 of 8