Beaconshire Nursing Centre

Provide and implement an infection prevention and control program.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficient practice pertains to 1232811.Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (R407) of three resident reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms.Findings include:On 9/16/2025 at 10:50 AM, Licensed Practical Nurse (LPN) A was observed to perform wound care and peri care on R407. LPN A was assisted by Certified Nurse Assistant (CNA) B. LPN A and CNA B did not put on a gown during patient care despite there being an Enhanced Barrier Precaution (EBP) sign on the door indicating R407 was on (EBP).During this time LPN C (unit manage) enter R407 room while wound care was being performed.On 9/16/2025 at 11:15 AM, CNA B was interviewed about (EBP) and said a gown should be worn when a resident has a foley catheter, wound and doing personal care.On 9/16/2025 at 11:17 AM, LPN A was interviewed and queried about the care they had performed on R407.

LPN A said she should have worn a gown because R407 had an open wound and a foley catheter.On 9/16/2025 at 11:49, AM LPN C was interviewed and acknowledged when they entered the room during patient care they did not see LPN A nor CNA B wearing a gown. LPN C said they should have been wearing a gown because R407 was on EBP.On 9/16/2025 at 1:00 PM, the Director of Nursing (DON) was interviewed and said they had the signs posted on door R407.

The DON also acknowledged there were orders in R407 chart indicating they were on EBP, but staff did not follow the orders or signs.

The DON said they would expect staff to follow the orders.

Record review revealed R407 was initially admitted on [DATE] and readmitted on [DATE]. R407 had the following diagnosis: urinary tract infection, osteomyelitis (bone infection), pressure ulcer stage IV, unspecified injury at C4 and neurogenic bowel.Review of Minimum Data Set (MDS) for R407 from the Quarterly Review dated 7/19/2025 noted R407 Brief Interview for Mental Status was a 15 out of 15 indicating R407 was cognitively intact.Review of facility policy titled, Enhanced Barrier Precautions with a review date of 9/16/2025 noted, It is the policy of this facility to implement enhanced barrier precautions for the prevention transmission of multidrug-resistant organisms.

Documented under implementation of enhanced barrier precautions indicated Personnel Protection Equipment (PPE), is for EBP is only necessary when performing high- contact care activities.

High contact care activities included providing hygiene, changing linen device care which included urinary catheter and wound care.

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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