Oak Ridge Healthcare Center

Based on observation, interview, and record review, the facility failed to maintain infection control practices for one of four sampled residents (Resident 1) when Enhanced Barrier Precautions (EBP, involves use of gown and gloves during high contact resident care designed to reduce transmission of Multi Drug Resistant Organisms [MDRO, bacteria resistant antibiotics]) were not in place or used during care.This failure increased the risk of higher infection rates, outbreaks, and potential resident harm in the 67-certified bed facility.Findings:Resident 1 was admitted to the facility mid 2025 with diagnosis which included kidney failure, kidney stones and difficulty urinating.During a review of Resident 1's Care Plan Report [CP], dated 8/24/25, the CP indicated, The resident has Indwelling Catheter [a thin, flexible tube that is inserted into the bladder to continuously drain urine].During an observation on 8/27/25 at 10:34 a.m. of Resident 1 in therapy room, Resident 1 was transferred to the wheelchair by the Physical Therapy Assistant (PTA).

The PTA was in close contact with Resident 1 and was not wearing a gown. Resident 1 had an indwelling catheter.During an interview on 8/27/25 at 10:50 a.m. with the PTA, the PTA stated Resident 1 was on Enhanced Barrier Precautions because of the indwelling catheter and confirmed he should have worn a gown when he worked with Resident 1.

Review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 6/2024, the P&P indicated, Enhanced Barrier Precautions [EBPs] are utilized to prevent the spread of multi-drug resistant organisms [MDROs].EBP employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.transferring.EBPs are indicated.for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.Examples of indwelling medical devices include: indwelling urinary catheters.During an observation on 8/27/25 at 11:31 a.m. of Resident 1's room.

There was no signage outside the room that indicated Resident 1 was on EBP.During a concurrent observation and interview on 8/27/25 at 11:40 a.m. of Resident 1's room with the Infection Preventionist Nurse (IP), the IP confirmed there was no signage outside the room.

The IP stated EBP included residents with indwelling catheters, and a sign should have been placed outside of the resident's room to inform staff of the precautions, We need to keep up with the EBP to keep infections from spreading .

During an interview on 8/27/25 at 3 p.m. with the Director of Nursing (DON), the DON stated she expected residents with an indwelling catheter to have EBP to prevent the spread of infection.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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