Dove Healthcare - Superior

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections.

This affected 1 out of 3 residents (R) reviewed. (R4) Certified Nurse Assistant (CNA) E did not doff contaminated gloves after emptying urine from catheter into graduate before continuing R4's cares.

Findings include: The facility policy, titled Enhanced Barrier Precautions, revised January 2025, states:.4.

High contact resident acre activities include:e.

Changing linens.f.

Changing briefs or assisting with toileting.g.

Device care or use.

Urinary catheters.Surveyor reviewed R4's record, which indicated R4 is on enhanced barrier precautions (EBP) for history of extended-spectrum beta-lactamase (ESBL) in the urine and R4 has a suprapubic catheter. On 08/26/25 at 3:15 PM, Surveyor followed CNA E into R4's room.

Surveyor observed CNA E don Personal Protective Equipment (PPE) before entering R4's room. CNA E pushed R4 into a shared bathroom which is used for R4 and R4's neighbor. R4 stood up and stand pivoted to toilet and sat down. CNA E pulled R4's pants down and proceeded to empty R4's catheter into graduate. CNA E threw used brief onto floor and not in garbage in the shared bathroom. CNA E opened catheter and emptied in graduate. CNA E closed catheter tubing and placed graduate off to the side on floor. CNA E then used same contaminated gloves to cleanse R4's bottom and pulled R4's pants back up. CNA E opened bathroom door with contaminated gloves and R4 walked out of bathroom. CNA E walked R4 over to wheelchair and then touched wheelchair with contaminated gloves. CNA E wheeled R4 to bed and assisted R4 to bed. CNA E took R4's shoes off with contaminated gloves. CNA E rearranged R4's bedside table that had lunch tray on bedside table. CNA E placed R4's call light within reach with contaminated gloves and then walked to R4's door. CNA E then doffed PPE and contaminated gloves then washed hands. On 08/26/25 at 3:25 PM, Surveyor interviewed CNA E and asked CNA E the process for utilizing PPE in an EBP room. CNA E reported that CNA E should have changed gloves right after emptying graduate with urine before touching other surfaces and CNA E did not. On 08/27/25 at 10:52 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation of staff utilizing PPE and hand hygiene practices in an EBP room and suprapubic catheter. DON B reported expectation is PPE is to be donned upon entering and frequent glove changes are to be performed.

Surveyor reported to DON B the observation of inappropriate glove use by CNA E. DON B reported that CNA E should have discarded contaminated gloves after emptying R4's urine in graduate, sanitized, and then reapplied new gloves.

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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