Health inspection·December 9, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for three of four residents (Resident #1, Resident #2, and Resident #5) reviewed for catheter and incontinence care. 1. The facility failed to ensure CNA B provided appropriate perineal care for Resident #1 when he failed to clean the resident's penis, scrotum, and pubic area on 10/07/25. 2.The facility failed to ensure CNA B provided appropriate catheter and perineal care for Resident #2, who was being treated for a urinary tract infection, when he failed to change the surface of the peri-wipes when cleaning the resident's penis, scrotum, and perineal area, failed to wipe the catheter tubing from the tip of the penis downward and failed to keep the urinary drainage bag below the bladder while providing care on 10/07/25. 3. The facility failed to ensure CNA B and CNA C maintained the urinary catheter drainage bag below Resident #5's bladder while they transferred the resident with a mechanical lift and while providing incontinence care and a bed bath on 10/07/25. These failures could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.Findings included: 1. Record review of Resident #1's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 11/27/24. Diagnoses included fracture of left femur, (thigh bone) mild intellectual disability and history of trans ischemic attacks (a brief stroke-like attack resolving within minutes to hours). Record review of Resident #1's 5-day MDS assessment, dated 09/08/25, reflected a BIMS score of 9 which indicated he was moderately cognitively impaired. He was dependent on staff for toileting hygiene and was occasionally incontinent of urine and bowel. Record review of Resident #1's care plan, initiated on 08/11/25, reflected, Resident requires assistance with ADLs.Interventions. Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs every shift.Resident has been identified at risk for pressure ulcer development or skin breakdown.Interventions.Check for incontinence frequently and as needed. Provide incontinence care fer each. In an observation on 10/7/25 at 08:45 a.m. CNA B entered Resident # 1's room and asked the resident if he was ready to get up for therapy and the Resident stated no,. CNA B stated he needed to check to see if he needed changed and the Resident stated OK. CNA B put on gloves and uncovered the resident revealing he had brown rings noted on the bed pad and sheet. CNA B stated this was his first check and change on the resident since he started his 6:00 a.m. shift. CNA B unfasted the resident's brief revealing it was slightly wet. CNA B had the resident roll onto his side and then took a peri-wipe and wiped from the front to the back of the anal area, revealing light brown smears with each wipe. CNA B then pushed the soiled brief down toward the residents' buttocks and rolled the stained sheet under the resident. CNA B changed his gloves but did not perform hand hygiene. He placed a clean sheet, a draw sheet and clean brief under the resident and had him roll to the other side Page 1 of 8 676390 676390 12/09/2025 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some while he pulled the soiled linen out and pulled the clean linen out from under the resident. He had the resident roll back onto his back and fastened the brief without cleaning his pubic area, penial shaft or scrotum. CNA B then unfasted the brief and took a peri-wipe and wiped once down each groin but still did not clean the penial shaft or scrotum. CNA B refastened the brief and straightened the residents covers. In an interview with Resident #1 on 10/07/25 at 08:50 a.m. he stated he was last changed yesterday evening but could not remember the time. He stated they usually come and change him when he calls for them to come and change him. 2. Record review of Resident #2's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 10/04/25. Diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and severe sepsis (body's extreme reaction to an infection) Record review of Resident #2's admission MDS assessment reflected it was in process and not complete. Record Review of Resident #2's Order summary report dated 10/07/25 reflected, Catheter care.every shift. Catheter drainage bag to gravity. with a start date of 10/05/25. Record review of Resident #2's care plan dated 10/06/25 reflected, Resident utilizing indwelling urinary catheter placing resident at risk for UTI.Interventions.Provide urinary catheter care per facility protocol every shift and as needed.The resident has a Urinary Tract infection. Interventions.Check at least every 2 hours for incontinence. Wash, rinse and dry soiled areas. In an observation on 10/07/25 at 09:10 a.m. CNA B entered Resident #2's room, put on gloves, but no gown and told him he was here to get him changed and dressed for therapy. CNA B went to the resident's bathroom to retrieve a urinal and proceeded to empty the resident's urinary drainage bag, which contained approximately 220 cc of clear yellow urine. CNA B unhooked the urinary catheter drainage bag and laid it on the bed and unfastened the resident's brief and wiped across his pubic area, down each groin and then wiped up the penile shaft up and down with several swipes, using the same wipe and without changing the surface of the wipe. CNA B did not clean the catheter tubing from the tip of the penis downward. CNA B rolled the resident to his side and wiped the anal area from front to back and placed a clean brief under him. CNA B put on clean gloves, with no hand hygiene and applied barrier cream to his buttocks and then rolled the resident over and with the same gloves applied barrier cream to his groin area and penial shaft. CNA B fastened the brief, removed his gloves and put on clean gloves with no hand hygiene and dressed the resident and assisted with transferring him from the bed to the wheelchair. CNA B hooked the urinary drainage bag under the wheelchair. 3. Record review of Resident #5's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 04/20/24. Diagnoses included primary lateral sclerosis (a rare progressive neurodegenerative disease that affects the central motor system in adults), neuromuscular dysfunction of bladder (condition where the nerves and muscles that control bladder function are impaired) and adult failure to thrive (a decline in older adults that manifest as a downward spiral of health and ability). Record review of Resident #5's quarterly MDS dated [DATE] reflected the resident had a BIMS of 14 which indicated he was cognitively intact. The resident was dependent on staff for all toileting and transfers, had a foley catheter and was always incontinent of bowel. Record review of Resident #5's Order Summary report dated 10/07/25 reflected, Catheter care.every shift. Catheter drainage bag to gravity. with a start date of 06/20/25. Record review of Resident #5's care plan dated 10/06/25 reflected, Resident utilizing indwelling urinary catheter placing resident at risk for UTI.Interventions.Monitor urinary catheter for proper placement, patency every shift and as needed.Provide urinary catheter care per facility protocol every shift and as needed. In an observation on 10/07/25 at 10:38 a.m. revealed CNA B and CNA C entered Resident #5's room to transfer resident from his recliner to the bed for incontinent care and 676390 Page 2 of 8 676390 12/09/2025 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bed bath. Both staff washed their hands, put on gloves and gowns. CNA B retrieved a urinal and proceeded to empty the resident's urinary drainage bag, which contained approximately 320 cc of clear yellow urine. Both staff hooked the mechanical lift sling to the lift and CNA C unhooked the urinary catheter drainage bag and laid it on the resident's lap. CNA B instructed CNA C to hang the urinary bag on the lower rung of the mechanical sling, which she did, but as they were raising the lift, Resident #5 pointed towards his feet, and CNA C unhooked the urinary drainage bag and once again placed it on the resident's lap. Urine was observed in the tubing draining back toward the residents body. The resident was transferred from the recliner onto his bed. Both staff rolled the resident side to side to remove the sling and CNA C unfasted the brief and provided catheter care. CNA B then placed the urinary drainage bag onto the bed, and CNA C told him to place it back on the bed rail. CNA B stated no it was fine on the bed. Both staff rolled the resident over on his side revealing he had large soft bowel movement. CNA C wiped from the front to the back, changing wipes with each swipe. CNA C then removed her gloves and put on new gloves without performing hand hygiene and both staff proceeded to provide resident his bed bath with the urinary drainage bag on the bed. In an interview on 10/07/25 at 11:15 a.m. with CNA B when asked about the proper steps for catheter care and incontinence care he stated he was supposed to go from front to back and wipe away from the body down the catheter tube. He stated he realized he had not cleaned Resident #1's front, which is why he opened up his brief, but stated he should have cleaned all of his penis and scrotum. He stated Resident #1 usually used a urinal but stated he did have accidents on occasion. He stated he was not sure if he had spilled the urinal since he was not soaked when he changed him. He stated he was supposed to provide catheter care every time they did incontinence care, and he had failed to do that for Resident #2. He stated he was supposed to wipe once and change the surface of the wipes and did not realize he had not done that. He stated he knew the catheter bag was to remain lower than the bladder but did not think it was an issue placing it on the bed. In an interview with CNA C on 10/07/25 at 11:40 a.m. she stated she knew she was supposed to keep the urinary drainage bag below the resident bladder but stated Resident #5 liked to hold the bag and she did not want to be rude. She stated she knew they were not supposed to lay the urinary drainage bag in the bed because it could not drain laying in the bed and tried to get CNA B to put it on the bed rail. She stated she had only been a CNA for about a year, but stated the facility had skills checked them and the Lead CNA had watched her several times. She stated she was really nervous with someone new watching her. In an interview on 10/07/25 at 1:10 p.m. with ADON A she stated the CNAs were new CNAs but stated they had been skills checked and in-serviced on infection control, incontinence care and catheter care and stated they all knew the proper steps. She stated she could only assume they were nervous. She stated the Lead CNA does skills checks on all of the CNAs and works closely with them on the floor. She stated the risk of having the urinary bag above the bladder was the back flow of urine which would lead to infection and not changing the surface of the wipes or cleaning from front to back was the introduction of germs. An interview with the Lead CNA on 10/07/25 at 1:20 p.m. she stated catheter care was to be performed anytime the staff provided incontinence care and staff were to clean the peri area including penis and scrotum for male residents then moving toward the buttocks. She stated they were to change the surface of the wipes with each stroke. She stated that by not providing accurate incontinence care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene. She stated the staff had also been instructed to maintain the urinary drainage bag below the bladder at all times. She stated she worked directly with the CNAs, and they all knew how to do it correctly. She stated she thinks they just got nervous. An interview with the Corporate Nurse on 10/07/25 at 2:30 676390 Page 3 of 8 676390 12/09/2025 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some p.m. she stated it was the expectation for all staff to provide timely and appropriate incontinent care and catheter care. She stated she could attribute some of it to nerves but stated they would do some re-education to ensure staff were following the correct procedures. She stated the risk of having the urinary bag above the bladder was the back flow of urine which would lead to infection. Record review of the facility's undated policy titled, Incontinence, reflected, .The facility will ensure that the resident who is incontinent receives appropriate treatment services to prevent urinary tract infections. Record review of the facility's undated policy, Catheter Care, reflected, Put on gloves.Wash the area around the catheter and perineal are well with mild soap and warm water, taking care to wash from front to back. DO NOT COMATAMINATE AREA WITH FECES. IF CONTAMINATION OCCURS WSAH YOUR HANDS AND OBTAIN CLEAN EQIPIPMENT TOR CATHETER CARE. Wash the catheter by cleaning gently from the meatus outward. For males, retract foreskin 0.5 to 1 inch to cleanse, being sure to replace it when finished.Cleanse area at catheter insertion well.Cleanse tubing with soapy and water in downward motion.Procedure should be done at least daily and after each bowel movement. 676390 Page 4 of 8 676390 12/09/2025 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

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, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 6 Residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) observed for infection control. 1.The facility failed to ensure CNA B performed hand hygiene during incontinence care to Resident #1 and failed to perform hand hygiene prior to leaving the resident's room on 10/07/25. 2. The facility failed to ensure CNA B used the required PPE for Resident #2, who was on Enhanced Barrier Precautions due to his urinary catheter, while providing incontinence care, failed to change gloves and perform hand hygiene during incontinence care and failed to perform hand hygiene before leaving the resident's room on 10/07/25. 3. The facility failed to ensure CNA C performed hand hygiene after assisting with Resident #3's mechanical lift transfer and before leaving the resident's room on 10/07/25. 4. The facility failed to ensure CNA D used the required PPE for Resident #4, who was on enhanced barrier precautions due to her urinary catheter and wound, while providing incontinence care, failed to change gloves and perform hand hygiene during incontinence care and failed to perform hand hygiene before leaving the residents room on 10/07/25. 5. The facility failed to ensure CNA C performed hand hygiene during incontinence care to Resident #5 and both CNA C and CNA B failed to perform hand hygiene prior to leaving the resident's room on 10/07/25. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: 1. Record review of Resident #1's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 11/27/24. Diagnoses included fracture of left femur, (thigh bone) mild intellectual disability and history of trans ischemic attacks (a brief stroke-like attack resolving within minutes to hours) In an observation on 10/7/25 at 08:45 a.m. CNA B was observed using the hand sanitizer in the hallway and then entered Resident # 1's room and asked the resident if he was ready to get up for therapy and the Resident stated no,. CNA B stated he needed to check to see if he needed changed and the Resident stated OK. CNA B put on gloves pulled out a packet of peri-wipes and a clean brief from the chest of drawers and uncovered the resident revealing he had brown rings noted on the bed pad. CNA B stated this was his first check and change on the resident since he started his 6:00 a.m. shift. CNA B unfasted the resident's brief revealing it was slightly wet. CNA B had the resident roll onto his side and then took a peri-wipe and wiped from the front to the back of the anal area, revealing light brown smears with each wipe. CNA B then pushed the soiled brief down toward the residents' buttocks and rolled the stained sheet under the resident. CNA B changed his gloves but did not perform hand hygiene. He placed a clean sheet, a draw sheet and clean brief under the resident and had him roll to the other side while he pulled the soiled linen out and pulled the clean linen out from under the resident. He had the resident roll back onto his back and fastened the brief without cleaning his pubic area, penial shaft or scrotum. CNA B then unfasted the brief and took a peri-wipe and wiped once down each groin and refastened the brief and straightened the residents covers. CNA B removed his gloves, gathered up the dirty linens and trash and left the room without performing hand hygiene. CNA B walked down the hall, opened the soiled linen room, deposited the soiled linens and trash and then used the hand sanitizer on the wall outside of the door. 2. Record review of Resident #2's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 10/04/25. Diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement), chronic kidney disease (long standing disease of the kidneys leading to renal failure) and severe sepsis (body's extreme reaction to an infection) In an Residents Affected - Some 676390 Page 5 of 8 676390 12/09/2025 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observation on 10/07/25 at 09:10 a.m. signage was observed outside of Resident #2's room which indicated he was on Enhanced Barrier Precautions. CNA B entered Resident #2's room, put on gloves, but no gown and told him he was here to get him changed and dressed for therapy. CNA B went to the resident's bathroom to retrieve a urinal and proceeded to empty the resident's urinary drainage bag, which contained approximately 220 cc of clear yellow urine. CNA B emptied the urinal, changed gloves but did not perform hand hygiene. CNA B unhooked the urinary catheter drainage bag and laid it on the bed and unfastened the resident's brief and wiped across his pubic area, down each groin and then wiped up the penile shaft up and down with several swipes, using the same wipe and without changing the surface of the wipe. CNA B did not clean the catheter tubing from the tip of the penis downward. Resident's penile shaft and groin area were noted to be red and irritated. CNA B rolled the resident to his side and wiped the anal area from front to back and placed a clean brief under him. CNA B then removed his gloves and without performing hand hygiene, searched the resident's chest of drawers for barrier cream. CNA B put on clean gloves, with no hand hygiene and applied barrier cream to his buttocks and then rolled the resident over and the same gloves applied barrier cream to his groin area and penial shaft. CNA B fastened the brief, removed his gloves and put on clean gloves with no hand hygiene and dressed the resident. CNA B removed his gloves, gathered the soiled linen and trash and left the room without performing hand hygiene. CNA B again walked down to the soiled linen closet on the hallway, disposed of the trash and linen and used the hand sanitizer outside of the door. 3. Record review of Resident #3's Face Sheet dated 10/7/25 reflected a [AGE] year-old female with an admission date of 10/03/25. Diagnoses included diabetes and chronic embolism and thrombosis of unspecified popliteal vein (blood clot that had formed in a deep vein in the lower leg located behind the kneecap). In an observation on 10/07/25 at 09:50 a.m. revealed CNA C and Lead CNA preparing to transfer Resident #3 with a mechanical lift. Both staff had on gloves, positioned the lift over the resident and transferred her from her bed to the wheelchair. Lead CNA removed her gloves, performed hand hygiene and left the room with the mechanical lift, while CNA C brushed the resident's hair. After completion of care, CNA C removed her gloves, gathered the trash and soiled linens and left the room without performing hand hygiene and walked down the hallway to the soiled linen closet, deposited the trash and linens and then used the hand sanitizer outside of the doorway. 4. Record review of Resident #4's Face Sheet dated 10/7/25 reflected an [AGE] year-old female with an admission date of 07/19/25. Diagnoses included candidiasis of the skin and nails (fungal infection especially in warm moist areas) dementia and urinary tract infection. In an observation on 10/07/25 at 10:15 a.m. signage was observed outside of Resident #4's room which indicated she was on Enhanced Barrier Precautions. CNA D used the hand sanitizer on hallway and entered Resident #4's room, put on gloves, but no gown and told her she was here to change her. CNA D uncovered the resident revealing she had urinary catheter that was secured to her right thigh. CNA D unfastened the resident's brief and wiped across his pubic area, down each groin and then wiped opened the resident's labia and wiped down the catheter tube using changing the surface of the wipe with each stroke. Resident was noted to be very red in her groin area. CNA D rolled the resident to her side revealing her buttocks to be very red and irritated and she had a dressing on her coccyx area. CNA D stated they had ordered cream for the resident's buttocks but stated the nurse would have to apply it. CNA D wiped from front to back and while wearing the same soiled gloves, placed a clean brief under the resident. CNA D repositioned the resident on her back and fastened the brief. CNA D removed her gloves, gathered the soiled trash and left the room without performing hand hygiene. CNA D walked down to the soiled linen closet on the hallway, disposed of the trash and used the hand sanitizer outside of the door. 5. Record review of 676390 Page 6 of 8 676390 12/09/2025 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #1's Face Sheet dated 10/7/25 reflected a [AGE] year-old male with an admission date of 04/20/24. Diagnoses included primary lateral sclerosis (a rare progressive neurodegenerative disease that affects the central motor system in adults), neuromuscular dysfunction of bladder (condition where the nerves and muscles that control bladder function are impaired) and adult failure to thrive (a decline in older adults that manifest as a downward spiral of health and ability). In an observation on 10/07/25 at 10:38 a.m. revealed CNA B and CNA C entered Resident #5's room to transfer resident from his recliner to the bed for incontinent care and bed bath. Both staff washed their hands, put on gloves and gowns. CNA B retrieved a urinal and proceeded to empty the resident's urinary drainage bag, which contained approximately 320 cc of clear yellow urine. CNA B emptied the urinal, changed gloves and washed his hands. Both staff hooked the mechanical lift sling to the lift and CNA C unhooked the urinary catheter drainage bag and laid it on the resident's lap. CNA B instructed CNA C to hang the urinary bag on the lower rung of the mechanical sling, which she did, but as they were raising the lift, Resident #5 pointed towards his feet, and CNA C unhooked the urinary drainage bag and once again placed it on the resident's lap. Urine was observed in the tubing draining back toward the residents. The resident was transferred from the recliner onto his bed. Both staff rolled the resident side to side to remove the sling and CNA C unfasted the brief and provided catheter care, wiping downward from the tip of the penis down, changing each wipe. CNA C then wiped down each groin. CNA B then placed the urinary drainage bag onto the bed, and CNA C told him to place it back on the bed rail. CNA B stated no it was fine on the bed. Both staff rolled the resident over on his side revealing he had large soft bowel movement. CNA C wiped from the front to the back, changing wipes with each swipe. CAN C then removed her gloves and put on new gloves without performing hand hygiene and both staff proceeded to provide resident his bed bath. In an interview with CNA D on 10/07/25 at 11:10 a.m. She stated she had received training and had been skills checked on incontinence care and enhanced barrier precautions. She stated she realized she had forgot to put a gown on when she went in to provide incontinence care to Resident # 4 and she should have changed her gloves and done hand hygiene after she finished cleaning her. She stated she was supposed to wash her hands before she left the room. She stated all of this was to prevent the risk of infections and spreading germs to other residents. In an interview on 10/07/25 at 11:15 a.m. with CNA B he stated he was supposed to perform hand hygiene before providing care and after you finished care. When asked about the proper steps for catheter care and incontinence care he stated he was supposed to go from front to back and wipe away from the body down the catheter tube. He stated he had changed his gloves but did not perform hand hygiene. He stated the signage on the door determine what type of precaution to a resident was in and what PPE needed to be worn. He stated he just forgot to put the gown on in Resident #2's room. He stated he had received infection control training on the enhanced barrier precautions and hand hygiene and stated the risk of not following the proper protocol was the spread of germs and infections. He stated he knew the catheter bag was to remain lower than the bladder but did not think it was an issue placing it on the bed. In an interview with CNA C on 10/07/25 at 11:40 a.m. she stated she was supposed to perform hand hygiene before care, after changing gloves and after care. She stated she realized she had forgotten her hand sanitizer when she went into Resident #5's room and should have washed her hands before she left Resident #3 room. She stated she knew she was supposed to keep the urinary drainage bag below the resident bladder but stated Resident #5 liked to hold the bag and she did not want to be rude. She stated she had only been a CNA for about a year, but state the facility had skills checked them and the Lead CNA had watched her several times. She stated knew it was important to perform hand hygiene correctly to prevent the spread of germs from resident to 676390 Page 7 of 8 676390 12/09/2025 Lexington Medical Lodge 2000 West Audie Murphy Pkway Farmersville, TX 75442

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident. In an interview on 10/07/25 at 1:10 p.m. with ADON A she stated staff were to wash their hands before care, change gloves and wash their hands when they went from dirty to clean, and after care was completed. She stated enhanced barrier precautions were noted on each resident who required extra PPE and expected the staff to always follow it. She stated the risk to residents was developing infection. She stated the three CNAs were all new CNAs but stated they had been skills checked and in-serviced on infection control. She stated the Lead CNA does skills checks on all of the CNAs and works closely with them on the floor. An interview with the Lead CNA on 10/07/25 at 1:20 p.m. she stated all of the staff had been instructed to wash their hands before care, after gloves changes and before leaving the room. She stated they had also been trained on which residents required Enhanced Barrier Precautions. She stated all of the residents who were on Enhanced Barrier Precautions had signage outside of their doors and supplies in their room. She stated she worked directly with all three of the CNAs and they all knew how to do it correctly. An interview with the Corporate Nurse on 10/07/25 at 2:30 p.m. she stated it was the expectation for all staff to adhere to the infection control protocol. She stated they would do some re-education to ensure staff were following the correct procedures. She stated she knew they had all been taught to wash their hands after incontinence and prior to leaving the room. Record review of the facility's undated policy, Enhanced Barrier Precautions (EBP), reflected, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistance organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with Standard Precautions and expand the use of PPE to donning gown and glove use during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hand and clothing. EBP are indicated for resident with.Wounds and/ or indwelling medical devices even if resident is not known to be infected or colonized with a MDRO.Indwelling medical device example.urinary catheters.feeding tubes. 676390 Page 8 of 8