Bishop Drumm Retirement Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to notify the family/emergency contact when a resident had a significant change of condition for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 114 residents.Findings include: Resident #10's Quarterly Minimum Data Set (MDS) dated [DATE REDACTED] assessment identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS identified Resident #10 was dependent on staff for eating . Resident #10's MDS included diagnoses of anemia, diabetes mellitus, traumatic brain injury, malnutrition and respiratory failure.

The MDS documented Resident #10 had weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician prescribed weight loss regimen. The MDS identified Resident #10 had a feeding tube and received 51% or more of the total calories through the feeding tube daily. A Progress Note dated 6/5/25 titled Dietary Note revealed Resident #10 had a weight loss of 8.8 pounds (5%) in one week. The note documented the dietician recommended switching tube feeding to prevent further weight loss. Review of the clinical record lacked documentation Resident #10's family/emergency contact was notified regarding the weight loss and recommendations from the dietician. A Progress Note dated 8/11/25 titled Dietary Note revealed Resident #10 triggered for weight loss. The note documented Resident #10 had a 11.9 pound weight loss (7.3%) in one month and 21.4 pound weight loss (12.4 %) in 3 months. A Progress Note dated 8/14/25 titled Dietary Note revealed the dietician recommended to increase the tube feeding rate to help prevent further weight loss. Review of the clinical

record lacked documentation Resident #10's family/emergency contact was notified regarding the weight loss and recommendations from the dietician. On 9/16/25 at 9:00 AM, the Director of Nursing (DON) verified she could not locate family notification for the weight loss in the medical record. She said she would expect family notification to be documented in the clinical record. She said she had multiple conversations with the family and did not document the conversations. A facility policy titled Notification of Changes revised 3/5/25 documented the purpose of the policy was to ensure the facility promptly informs the resident, consults the resident's physician and notifies the resident's representative when there was a change requiring notification. The policy documented circumstances requiring notification include significant change in the resident's physical condition or a circumstance that required a need to alter treatment.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Drumm Retirement Center

5837 Winwood Drive Johnston, IA 50131

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 0658

staff to weigh Resident #79 and to note significant increases and decreases.

Level of Harm - Minimal harm or potential for actual harm

A Physician Order dated 1/24/25 directed staff to obtain weekly weights every Sunday for nutrition monitoring.

Residents Affected - Few

Review of Weight Summary and TARs for March to September 2025 revealed the weekly weights were not obtained for the following dates: 3/9, 3/16, 4/6, 5/11, 5/25, 6/8, 7/6, 7/27, 8/3, 8/17, 8/31 and 9/14.

On 9/16/25 at 11:54 AM, the Dietician reported she expected residents with feeding tubes to have weights completed weekly to monitor their nutritional status. She said she had noticed obtaining weekly weights had been a problem. She reported she believed the Director of Nursing (DON) and Administrator were aware of

the issue. She said some of the scales had been broken and needed to be repaired. She said a weight scale had been added to the shower room. She said there had also been concerns with staff obtaining accurate weights.

On 9/16/25 at 10:45 AM, the Administrator in training/ Infection Preventionist said she expected staff to obtain weights according to physician orders.

A facility policy titled Weight Monitoring revised 11/28/22 documented weights could be a useful indicator of nutritional status. Significant unintended changes in weight or insidious weight loss may indicate a nutritional problem. The policy directed staff to implement a weight monitoring schedule upon admission for all residents and weights should be recorded at the time they are obtained.

1. 3. The Quarterly MDS for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy,

respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition. The MDS identified the resident had a feeding tube (tube into the stomach to provide liquid nutrition) and was dependent on staff for eating, toilet hygiene. and transfers. The MDS indicated the resident had a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing). The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment.

Resident #15's Medication Administration Record (MAR) for 8/1/25 - 8/31/25 and 9/1/25 – 9/30/25 revealed the following physician orders: a. daily weights X 3 and then weekly for nutrition monitoring, on time a day every Sunday with start date of 5/4/25. b. weight monitoring every day shift every Friday with start date 6/13/25.

Resident #15's MAR for 8/1/25 – 8/31/25 and 9/1/25 – 9/30/25 revealed only 1 weight on 8/31/25 of 124.4 pounds.

Resident #15's Weights and Vitals record revealed weights documented on 7/4/25, 8/31/25, and 9/3/25 only.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Drumm Retirement Center

5837 Winwood Drive Johnston, IA 50131

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 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

turning and repositioning to be documented in the resident's care plan and be determined by the resident's tissue tolerance, level of activity/mobility, skin condition, overall medical condition, treatment goals, type of pressure redistribution support surface, comfort level and resident preferences. The policy further directed staff to ensure that heels are floated off the surface of the bed with pillows or devices designed to do so. If using a heel protector, the heel must still be floated. A facility policy titled Pressure Injury Prevention and Management revised 9/11/25 documented the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The policy further documented the facility would establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce, or remove the underlying risk factors; monitoring the impact of interventions, and modifying the interventions as appropriate. In addition the policy documented licensed nurses would conduct a full body skin assessment

on all residents upon admission/readmission, weekly, and after any new identified pressure injury. The finding of the skin assessment would be documented in the medical record. After completing a thorough assessment/evaluation, the interdisciplinary team should develop a care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.

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Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Drumm Retirement Center

5837 Winwood Drive Johnston, IA 50131

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on observation, clinical record review, staff interview, and policy review the facility failed to provide appropriate suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) care for 1 of 3 residents (Resident #15) reviewed. The facility reported a census of 114 residents.Findings include:The Quarterly Minimum Data Set (MDS) for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy, respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition. The MDS identified the resident was dependent on staff for eating, toilet hygiene. and transfers. The MDS indicated

the resident had a suprapubic catheter and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing). The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment. Observation on 9/15/25 at 2 PM, Staff A, Registered Nurse with the same pair of gloves on completed the 2 wound treatments, removing the old dressings, cleansing the wounds, and applying new dressings on Resident #15. Staff A then proceeded to remove the old suprapubic catheter dressing on Resident #15, applied wound cleanser to a gauze pad and wiped around the suprapubic catheter insertion site 4 times continuing to wipe in the same areas with the same area of the gauze pad.

Staff A continued with the same gloves on, and proceeded to apply a new dressing around the suprapubic catheter. Resident #15's electronic health record progress notes revealed the following:a. Nurse's Note 8/16/25 at 6:09 AM- Nurse was summoned to the resident's bedside for complaints of blood in the urine, blood observed in the tubing of the indwelling suprapubic catheter and large sediment in the catheter tubing. Resident transferred to the hospital emergency room (ER). b. Encounter Note, 8/21/25 - resident seen for an acute visit, recent ER visit for hematuria (blood in urine) in foley catheter bag. Resident returned to the facility. Received urinalysis culture and sensitivity (C&S) (test for bacteria and antibiotic that bacteria is sensitive to) report indicating a urinary tract infection. Order left in facility for antibiotic medication. Resident #15's lab report from the hospital revealed a urinalysis completed on 8/16/25 and C&S resulted on 8/19/25 with Enterococcus species(bacteria) count over 100,000. The facility Suprapubic Catheterization policy approved 9/17/25 revealed wash and dry hands, apply gloves, and clean the stoma (insertion site in abdomen of suprapubic catheter), cleansing outward from for the stoma in a circular motion using only 1 cotton ball or applicator for each stroke. Interview on 9/16/25 at 9 AM, the Infection Control Preventionist stated expectation when changing the dressing and cleaning the suprapubic catheter site to remove the old dressing, complete hand hygiene, apply new gloves and cleanse around the catheter working from the insertion site outward with the gauze pad or cotton ball, not wiping over the same area again.

Event ID:

Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Drumm Retirement Center

5837 Winwood Drive Johnston, IA 50131

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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Based on observation, clinical record review, staff interview, and policy review the facility failed to flush an enteral gastrostomy tube (g-tube) (tube surgically inserted into the stomach to provide nutrition and medication) per facility policy prior to and after administering medication thru the g-tube for 1 of 3 resident (Resident #15) reviewed. The facility reported a census of 114 residents. Findings include:The Quarterly Minimum Data Set (MDS) for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy, respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition. The MDS identified the resident had a g-tube and was dependent on staff for eating, toilet hygiene. and transfers. The MDS indicated the resident had a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing). The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment.Observation on 9/15/25 at 2:30 PM, Staff A, Registered Nurse was sitting on the side of Resident #15's bed and applying tape to the g-tube adaptor port (end of g-tube that attaches to the tubing from the container that provides

the feeding product). Staff A had a syringe with approximately 25 milliliters (ml) of pink liquid. Staff A proceeded to attach the syringe to the g-tube and administered the liquid into the resident's g-tube, without flushing the g-tube before or after administering the liquid in the syringe. Staff A stated the pink liquid was 3 of the resident's medication and an unknown amount of water, as there was no set amount for the water flush so it didn't really matter.The facility's Medication Administration via Enteral Tube policy revised 9/16/25, revealed flush enteral tube with at least 15 ml. of water prior to administering medications, dilute

the solid or liquid medication as appropriate and administer, and flush tube again with at least 15 ml. water.Interview on 9/16/25 at 9 AM, the Director of Nursing stated her expectation to follow the physician's order for flushing a g-tube before and after medication administration, and if no order to follow the protocol which is 30 or 60 ml. of water to flush before and after medications given.

Event ID:

Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Drumm Retirement Center

5837 Winwood Drive Johnston, IA 50131

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

room, providing oral care to resident. Call light remained on the floor.i. 2 PM - 3 staff entered the resident's room and provided cares. Call light picked up off floor and placed within reach of resident after cares completed. Facility policy Call Lights: Accessibility and Timely Response, last approved 8/5/25, revealed the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside to allow residents to call for assistance and staff will ensure the call light is within reach of resident and secured, as needed. Interview on 9/16/25 at 9 AM, the DON stated expectation for call lights to be within reach of the residents.

Event ID:

Facility ID:

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Drumm Retirement Center

5837 Winwood Drive Johnston, IA 50131

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 0865

Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or potential for actual harm

Based on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past surveys, and staff interview, the facility failed to correct their own deficiencies and have an effective quality assurance program in place to assist in the provision of quality of care for residents and attain substantial complaining with Federal regulation and State rule. The facility reported a census of 114 residents. Findings include: Review of the Department of Inspections Appeals and Licensing (DIAL) website under the facility's visit history revealed the facility had the following concerns identified at the current revisit and complaint survey, that were also cited at past surveys in the last two and half years. a. F-F686- Pressure Sores b. F-F658- Services to Meet Professional Standardsc. F-F725- Sufficient Nursing Staffingd. F880Infection ControlThe following surveys revealed repeated deficiencies from 6/29/23 to current survey:7/21/25- Recertification, Complaint, Incident Survey: F-F725, F-F8804/3/25- Complaint, Incident: F-F7259/19/24- Recertification, complaint, Incident: F-F8808/18/24- Complaint revisit: F-F6866/27/24- Complaint: F-F686, F-F7255/3/24- Complaint: F-F6582/27/24- Complaint, Incident: F-F658, F-F686, F88010/9/23- Complaint, Incident, Recertification revisit, Complaint Revisit, Incident Revisit: F-F725, F-F8806/29/23- Recertification, Complaint, Incident: F-F725, F880A Quality Assurance and Performance Improvement Plan (QAPI) dated 2/26/25 documented the facility used a systematic approach to determine when in-depth analysis was needed to fully understand identified problems, causes of the problems, and implications of a change. The policy further documented that to prevent future events and promote sustained improvement the facility would develop actions to address the identified root cause and/or contributing factors of an issue/event that would affect change at the systems level. To ensure the planned changes/interventions are implemented and effective in making and sustaining improvements, the facility would choose indicators/measures that tie directly to the new action and conduct ongoing periodic measurement and review to ensure that the new action has been adopted and was performed consistently.In an interview on 9/17/25 at 1:45 PM, the surveyor asked the Administrator what the facility had done to improve and address the repeat deficiencies from the current survey and prior surveys. The Administrator acknowledged the repeated deficiencies and stated that the facility had put in place quite a few things to improve and address the deficiencies. He said

the facility had implemented new wound assessments/tracking and had hired a wound nurse. The Administrator reported he thought the facility had a good process in place for pressure wounds until the current survey identified concerns. He said the facility was tracking infection control in a different way so trends could be identified easier. He said the facility was conducting routine audits and reviewing resident infections. The Administrator reported the facility was working with an outside quality of care coalition on a monthly basis to share information, resources and review quality of care outcomes. He said the facility had been tracking call lights and had made some changes on how the staff were scheduled and supported. He said he felt call lights had improved. The Administrator reported the concerns identified through the survey process would be reviewed and discussed through QAPI.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bishop Drumm Retirement Center

5837 Winwood Drive Johnston, IA 50131

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

Based on observations, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 1 of 5 residents reviewed (Resident #15). The facility failed to ensure use of enhanced barrier precautions (EBP)when required and failed to complete hand hygiene and change gloves when completing treatments. The facility reported a census of 114 residents. Findings include:1.The Quarterly Minimum Data Set (MDS) for Resident #15, dated 7/24/25, included diagnoses of Muscular Dystrophy, respiratory failure, dysphagia (difficulty swallowing food or liquids), and malnutrition. The MDS identified the resident was dependent on staff for eating, toilet hygiene. and transfers. The MDS indicated

the resident had a gastrointestinal feeding tube (g-tube) (tube into the stomach to provide liquid nutrition) a suprapubic catheter (tube into the lower abdomen to drain urine from the bladder) and a tracheostomy (opening with tube into the windpipe to maintain an airway for breathing). The MDS indicated the resident had a BIMS score of 12, indicating mild cognitive impairment. Resident #15's Care Plan with revision date 11/13/24 documented the resident required Enhance Barrier Precautions (EBP) with close contact due to presence of catheter. 2.Observation on 9/15/at 1:59 PM, the Infection Control Preventionist (ICP)was in Resident #15's room providing oral care with only gloves on, no gown on. 3.Observation on 9/15/25 at 2 PM, Staff A, Registered Nurse (RN) applied a gown and gloves and entered Resident #15's room. Staff A removed an old dressing off the resident's left buttock, cleansed an open wound with wound cleanser and a gauze pad, and applied a new dressing with an ordered treatment paste. Staff A continued with the same gloves on and remove an old dressing from the resident's right buttock, cleansed the wound area and applied a new dressing. Staff A then proceeded with the same gloves on and removed the old suprapubic catheter dressing on the resident, cleansed the catheter insertion site, and applied a clean dressing to the site. Staff A, still with the same gloves on, removed the old dressing from the g-tube site, cleansed the site area with wound cleanser and gauze, and applied a new dressing. Staff A continued with the same gloves

on and removed the tracheostomy dressing, cleansed around the tracheostomy, and applied a clean dressing. 4.Observation on 9/15/25 at 2:30 PM, Staff A, was sitting on the side of Resident #15's bed administering to the resident per g-tube, without a gown or gloves on. Facility Enhanced Barrier Precautions policy, revised 9/16/25, revealed EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities with high-contact resident care activities include device care of feeding tubes, tracheostomy tubes, urinary catheters, and wound care. Facility Hand Hygiene policy, revised 9/16/25, revealed hand hygiene is indicated and will be performed under the conditions listed: after handling contaminated objects and before and after handling clean or soiled dressings. Interview on 9/16/25 at 9 AM, the ICP acknowledged she observed Staff A not complete hand hygiene or change gloves when completing dressing changes for Resident #15 and stated expectation to complete hand hygiene and change gloves when going from dirty to clean when completing dressing changes. The ICP additionally stated her expectation for staff to wear gown and gloves with high contact care such as administering medications per a g-tube.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

If continuation sheet