Hillcrest Nursing Center

Based on observation, interview, facility policy review, and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were implemented in accordance with facility policy and current infection control standards during percutaneous endoscopic gastrostomy (PEG) tube care for (1) one of (3) three care observations. (Resident #1) Findings Include:A review of the facility's policy Enhanced Barrier Precautions with a revision date of 03/24 revealed Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes.

Enhanced Barrier Precautions involve gown and gloves use during high-contact residents care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices) .On 12/22/25 at 12:22 PM during an observation of Registered Nurse #1(RN)/ Nurse Supervisor performing PEG tube care she did not apply a gown during care. On 12/22/25 at 1:15 PM in an interview with RN #1 stated she uses a gown when resident has a PEG tube and care is prolonged or heavy drainage at the site.

She stated the gown is used to protect the residents from the staff.

She stated by her not wearing a gown the resident has an increased risk of getting an infection.On 12/22/25 at 2:44 PM an interview with Licensed Practical Nurse #1(LPN)/ Infection Preventionist nurse stated that EBP consists of a gown and gloves and should be used when a resident has colonized wounds, indwelling catheter and PEG tube.

She stated EBP is used to protect the residents from the staff.

She stated it also protects the staff from any organism the resident may have.

She stated RN #1 could have transferred something from her uniform to the resident.

She stated there could be a possibility the resident could get sick.On 12/23/25 at 10:57 AM an interview with Director of Nursing (DON) confirmed that RN #1 should have had a gown on while doing PEG tube care.

She stated that Resident #1 is at high risk for infection due to PEG tube.

She stated the gown protects the resident from getting something the nurse may have on her uniform.

She stated there is a chance of spreading infection when a nurse does not wear a gown while doing high contact care. A record review of Resident #1's admission Record revealed an admission date of 12/12/24 with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side and Dysphagia, Oropharyngeal Phase.A record review of Resident #1's Physician orders revealed clean 18FR(french)/20 ml(milliliter) PEG tube site with normal saline, pat dry with 4x4 gauze, apply split sponge daily.A record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) 10/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicates moderate cognitive impairment.A record review of the EBP signage on the door revealed everyone must wear gown and gloves for the following high-contact care activities.

Device care or use: feeding tube.

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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