Park Village Healthcare And Rehabilitation

CNA C and CNA D put on gloves and gowns to provide incontinence care before entering the room. CNA C said the resident was on EBP. CNA C said the sign was posted, but another resident in the facility would walk around and take down the signs. CNA C assisted the resident to turn to his left side.

His brief was soiled with bowel movement. CNA C began cleaning the bowel movement. CNA C changed gloves and said I'm supposed to use hand sanitizer, but I don't have it. I'm supposed to use it between each glove change.

CNA C changed gloves, but did not perform hand hygiene.

The sacral area had two pinpoint openings areas. CNA C cleaned the area thoroughly, removed her gloves, and washed her hands. CNA C put down a clean brief and the resident was turned to his right side. CNA D cleaned the resident's other side of buttocks, and the resident was turned to his back. CNA D cleaned the resident's penis and scrotum. CNA D did not change gloves or perform hand hygiene. CNA D used the soiled gloves to apply cream to the resident's peri-area and fastened the brief. CNA D removed her gloves and washed her hands. An interview on 08/20/25 at 10:55 AM with CNA C revealed she said she did not perform hand hygiene.

She said she should have gone in and washed her hands.

She said the risk to Resident #2 was a possible transfer of infection. An interview on 08/20/25 at 12:55 PM with CNA D revealed she knew to change gloves and perform hand hygiene during incontinence care.

She said she did not because, there was a lot going on.

CNA D said the risk to Resident #2 was infection control. An interview on 08/20/25 at 1:10 PM with ADON E revealed she was the infection preventionist.

She said EBP were used for residents with wounds, indwelling devices, and tracheostomies. ADON E said EBP were important to reduce risk of spread of infection. ADON E said with EBP, staff were supposed to wear a gown, gloves, and face shield (if spills were possible).

She said the staff were trained on EBP in August 2025. ADON E said a resident on EBP was supposed to have a sign on the door and PPE in close proximity.

She said Resident #2 did not have a sign posted because another resident in the facility would take the signs down.

She said everyone was responsible for ensuring signs were kept posted, and she did not know why the resident did not have a sign posted on 08/20/25. ADON E said staff were supposed to wear appropriate PPE for EBP. ADON E said staff were supposed to change gloves and perform hand hygiene during wound care after cleaning the wound. ADON E said failure to wear appropriate PPE, change gloves, and perform hand hygiene placed the residents at risk for infection. ADON E said if staff were not aware of a resident being on EBP, there was a risk of transmission of infection.

Record review of the facility in-service, PPE Donning and Doffing and EBP, dated 08/10/25, reflected:LVN A did not sign the in-service.MA B, CNA C, and CNA D signed the in-service.

Record review of the facility in-service, Infection Prevention - Hand Washing/Hand Sanitizer, dated 08/10/25, reflected:LVN A did not sign the in-service.CNA C and CNA D signed the in-service.

Record review of the facility policy, IPCP Standard and Transmission - Based Precautions, revised October 2022, reflected: .3.

Enhanced Barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transferred to residents or from resident-to-resident.

Record review of the facility policy, IPCP Standard and Transmission - Based Precautions, revised October 2022, reflected: When and How to Clean Hands.Before or after caring for someone who is sick.

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