Providence Anderson

F-F761.

3.1-52(b)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 155005 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155005 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011

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 42685 potential for actual harm Based on observation, interview, and record review, the facility failed to follow infection prevention and Residents Affected - Few control procedures during wound care related to Enhanced Barrier Precautions (EBPs) for 2 of 5 resident reviewed for skin impairments. (Residents 70 and 83)

Findings include:

During an observation on 6/24/24 at 11:02 a.m., Resident 70's door was closed with an Enhanced Barrier Precaution sign noted on the left side of the door. A personal protective equipment (PPE) canister was to the left of the door just outside the resident door. The sign was readily visible and indicated to use hand hygiene,

a gown, and gloves for all high contact resident care to include wound care.

During a wound observation and interview on 6/27/24 at 2:38 p.m., LPN 12 and CNA 13 entered Resident 70's Enhanced Barrier Precaution room with the sign visible to the left side of the door along with the personal protective equipment canister. They both performed hand washing, donned gloves, then LPN 12 set everything up for wound care. LPN 12 used gloved hands and removed the moderately soiled dressing from the resident's right buttock. CNA 13 was there to assist with the wound care. Neither LPN 12 nor CNA 13 donned a gown. Throughout wound care, both LPN 12 and CNA 13 leaned up against the resident's mattress with their unprotected clothing. The wound bed on the right buttocks was covered with slough and consistent with the last wound assessment measurements and description.

Resident 70's clinical record was reviewed on 6/26/24 at 4:20 p.m. A current physician order, dated 4/25/24, included the following: Enhanced Barrier Precaution Isolation for high contact resident activity. Gown and glove use was required for dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), or wound care every shift.

During an observation on 6/24/24 at 11:59 a.m., Resident 83's room had an Enhanced Barrier Precaution sign noted to the left of her door. Upon entry to the room, the Personal Protective Equipment (PPE) canister was located behind the door in a canister.

Resident 83's clinical record was reviewed on 6/27/24 at 10:22 a.m. A current physician's order, dated 4/25/24, included the following: Enhanced Barrier Precaution Isolation for high contact resident activity. Gown and glove use was required for dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), or wound care every shift.

During a wound observation on 6/27/24 at 3:39 p.m., LPN 12 approached Resident 83's room with an Enhanced Barrier Precaution sign hung on the left side of the resident's door. The sign indicated high contact care such as wound care required hand hygiene, a gown, and gloves. Upon entry to the resident's room, LPN 12 washed her hands. She donned gloves for wound care but did not wear a gown for the wound care. Upon removal of the dressing, the wound to the left lateral foot was open and slightly smaller than the tip of

an eraser with a discernable depth. A small amount of serous drainage was noted on the removed dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 155005 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155005 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beaumont Rehabilitation and Healthcare Center 1345 N Madison Ave Anderson, IN 46011

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 During an interview on 6/27/24 at 4:00 p.m., LPN 12 indicated Residents 70 and 83's rooms had EBP signage on the doors, readily visible prior to entry to the rooms. She had just performed wound care with Level of Harm - Minimal harm or both of these residents without the use of a gown in either room. She was uncertain if both of the residents potential for actual harm were listed for use of EBPs during wound care or if the sign was posted for their roommates.

Residents Affected - Few During an interview on 6/27/24 at 4:10 p.m., LPN 10 indicated any high contact care for residents with open wounds required the use of EBPs. Required personal protective equipment (PPE) included proper hand hygiene, gown, and glove use. Wound care was considered high contact care.

During an interview on 6/27/24 at 4:14 p.m., CNA 13 indicated she was uncertain what PPE should have been worn for EBPs and when EBPs should have been utilized or implemented. She had just assisted with wound care in Resident 70's room with an EBP sign on the door. She had not worn a gown during the wound care. She then read the EBP sign on the door and indicated she should have worn a gown in addition to her gloves during the wound care for Resident 70.

During an interview on 6/27/24 at 4:19 p.m., LPN 12 indicated both Resident 70 and Resident 83 had orders for EBPs. She had not worn a gown during wound care for Resident 70 and Resident 83 on this date. EBPs required a gown and gloves use for high contact care such as wound care.

During an interview on 7/1/24 at 2:50 p.m., the DON indicated EBPs should have been followed by all staff

during wound care. The facility followed physician's orders as it was a nursing standard of practice.

A current undated facility policy, titled Enhanced Barrier Precautions, provided by Corporate Nurse Consultant 7 on 7/1/24 at 8:45 a.m., indicated the following: Policy Statement . Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms . Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a) Gloves and gown are applied prior to performing the high contact resident care activity . 3) Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . h) wound care

3.1-18(b)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 155005