Magnolia Ridge Health And Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while performing midline care for the residents who were on enhanced barrier precautions (EBP) to prevent the possible spread of infection and communicable diseases for 1 of 2 residents reviewed for intravenous (IV) therapy (Resident #4).

Findings include:During an observation on 11/20/2025 at 10:05 AM, Staff A, Licensed Practical Nurse (LPN), entered Resident #4's room, performed hand hygiene with hand sanitizer, and donned gloves.

Staff A proceeded to turn off the IV pump and then disconnected the IV tubing from Resident #4's midline.

Staff A wiped the midline port with an alcohol wipe and flushed 10 milliliters of normal saline into the midline.

Staff A wiped the midline port with another alcohol wipe and applied a green cap to the midline.

Staff A doffed the gloves and performed hand hygiene using hand sanitizer on her way out of the room.

Staff A did not wear a gown.During an interview on 11/20/2025 at 10:07 AM, Staff A, LPN, stated, Enhanced barrier precautions are for residents with certain types of infection, wounds, and catheters. I've also seen enhanced barrier precautions used for feeding tubes. I don't normally wear a gown for midlines or IVs. I just wear gloves.

During an interview on 11/20/2025 at 12:00 PM, the Director of Nursing stated, I expect nurses to use enhanced barrier precautions every time they take care of a resident who has a break in their skin, G-tubes [gastric tubes], wounds, IVs, PICC [peripherally inserted central catheter] lines, and foley catheters.Review of Resident #4's physician order dated 11/18/2025 read, Enhanced Barrier Precautions for wounds, IV every shift.

Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting. (EBP is required for residents with indwelling medical devices, wounds, or colonization with an MDRO [multi-drug-resistant organism]). every shift for Prophylaxis.

Review of the facility policy and procedure titled Clinical Guidelines, PPE in Use to Prevent Spread of MDROs dated 10/2024 read, Purpose: Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MRDOs).

Procedure: 1.

Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2.

Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Chronic wounds or indwelling medical devices, regardless of MDRO colonization status.

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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