UT Health East Texas Rehabilitation Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 10135 Based on observation, interview and record review, the facility failed an organized nursing services. The facility failed to ensure: A. Ensure sufficient numbers of registered nurses (RN’s) and patient care technicians (PCT’s) on 2 of 2 rehabilitation floors (3rd and 4th floor). The facility failed to ensure: There were sufficient numbers of patient care technicians (PCT’s) from 07/4-21/2025. There were sufficient numbers of registered nurses (RN’s). The staffing matrix was correctly utilized. The facility interchanged RN’s with license vocational nurses (LVN’s). A designated RN to supervise the units when the charge nurse was floating between the 3rd and 4th floor. Refer to A tag 0392 for additional information. B. Nurses evaluated and provided pressure sore treatment for 1 (Patient #3) of 5 (Patient #’s 2,3,5,7 and 8) patients on the sample that were reviewed for pressure sores. The facility failed to ensure: Thorough skin assessments with measurements were documented on Patient #3. Physician orders were obtained for treatments to pressure sores on Patient #3. Timely incontinent care and preventative cushioning were provided to Patient #3 who was at high risk for skin breakdown. Refer to A tag 0395 for additional information.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure sufficient numbers of registered nurses (RN’s) and patient care technicians (PCT’s) on 2 of 2 rehabilitation floors (3rd and 4th floor). The facility failed to: A.) ensure sufficient numbers of Patient care technicians (PCT’s) from 07/4-21/2025. B.) ensure sufficient numbers of Registered nurses (RN’s) C.) ensure the staffing matrix was correctly utilized. The facility interchanged RN’s with license vocational nurses (LVN’s). D.) ensure a designated RN to supervise the units when the charge nurse was floating between the 3rd and 4th floor. This deficient practice had the likelihood to cause harm to all patients on both rehab units. Findings include: During confidential interviews the following was stated: “Been (a patient) here about 3 weeks. They are a little lax when it comes to baths. I wipe myself off once a week. I just got a shower this morning.” “There is one free charge nurse from 6:00 a.m. - 6:30 p.m. who covers the 3rd and 4th floor. The nurses have 7 patients each. The charge nurses determine the staffing, and they try blocking. The staffing matrix does not factor in acuity. When the PCT (patient care techs) have 10-11 patients it’s stressful during those times. Staffing today on the 3rd floor is one sitter for 1 patient and one PCT for 21 patients. The 4th floor has 2 PCT’s for 20 patients.” “I have 10 patients today. Normally I have 7-10 patients. If I have the type of patients that I have to assist with feeding and ones that need more assistance we need 3 PCT’s.” “They say the ratio should be 11 or 12” patients for PCT’s.” We have to do the blood sugars, showers, linen change, incontinent care, assist with breakfast/lunch/dinner, vital signs and weights on Wednesdays. I have 10 patients and 5 have showers today. Sometimes I have to skip them on days and pass it on to the night shift.” I feel like I can’t take care of my patients. It’s 10 a.m. and I have not charted yet.” “We have 3 nurses who each have 7 patients. Seven is a heavy load for rehab because we have to work around therapy all day. Four to five patients would be more comfortable. We help the PCT’s too. The acuity is different. They are bringing in patients with higher acuities.” “Staffing is 3 nurses and 2 PCT’s for 21 patients. There is one full time charge nurse, and they don’t take patients. The charge nurse is the house supervisor. We are short staffed. We have a heavy load and have to pass medications, wound care, turning and assisting with ADLs (activities of daily living). If I am not able to get to wound care I pass it to the next shift.” “There are 2 PCT’s to 10 patients. We have to assist with breakfast, change briefs, incontinent care, take patients to restroom, empty Foley catheters, linen changes, baths, and take vital signs in the afternoon.” “Staffing with 2-3 nurses with usually 7 patients each. Sometimes there are not even two PCT’s. Yesterday a PCT left at 3 p.m. and no one covered for the PCT the rest of the shift. The nurses had to take up the slack. It’s a lot especially when inexperienced nursing has to be helped, teaching new nurses and the patient acuity has increased. There are more PICC lines, tube feedings and wound vac’s.” “Sometimes staffing is okay and sometime its not. The maximum number of patients taken are 12. Today I have 9 patients. Two patients have to be turned every two hours, 6 need showers, and 7 are incontinent patients. Sometimes it does not get done.” Review of the facility’s staffing sheets and staffing matrix with Staff #3 on 07/21/2025 after 2:21 p.m. revealed the following: 3rd FLOOR 7:00 a.m.-7:00 p.m. shift On 07/04, 07/10, 07/12, 07/13 there was 2 PCT’s for a census of 19. On 07/05 07/07, 07/08 and 07/14 there was 2 PCT’s for a census of 18. On 07/06 there was 1 PCT for a census of 19. On 07/09, 07/15, 07/16 and 07/17 there was 2 PCT’s for a census of 20. On 07/11 there was 2 PCT’s for a census of 17. On 07/18, 07/19, 07/20 and 07/21 there was 2 PCT’s for a census of 21. According to the facility’s staffing matrix the PCT to patient ratio was supposed to be 1:9. The PCT’s were working over this ratio. On 07/05, 07/06, 07/10, 07/11, 07/13, 07/15, 07/16, 07/17, 07/18, 07/19, and 07/20 there was a LVN (licensed vocational nurse) working according to facility staffing sheets. The facility’s total census for both floors for 07/04-07/21 for the 7:00 a.m.-7:00 p.m. shift ranged from 30 -42 patients. According to the facility’s staffing matrix there should have been 5-7 RN’s for this range. On 07/18 and 07/19 the total patient census for the 3rd and 4th floors was 42. The staffing matrix called for 7 RN’s, but the facility used 5 RN’s and 1 LVN. The facility was 2 RN’s short. There was no allowance for interchanging RN’s with LVN’s according to the facility’s staffing matrix. During an interview on 07/21/2025 after 2:21 p.m., Staff #3 said the charge nurses determined the staffing for the floor. The charge nurse was free floating and supervised both floors. The charge nurse was the LVN’s main resource, but all RN’s supervised the LVN’s. When she floated from 3rd to 4th floor there was no one RN designated on the schedule to supervise the LVN’s. Staff #3 said the staffing numbers for the 3rd and 4th floor are figured together as one instead of each separate unit. 7:00 p.m.-7:00 a.m. shift On 07/04, 07/06, 07/07 and 07/13 there was 2 PCT’s for a census of 18. On 07/05, 07/09, 07/11, 07/12 there was 2 PCT’s for a census of 19. On 07/08, 07/14, and 07/15 there was 2 PCT’s for a census of 20. On 07/10 there was 2 PCT’s for a census of 17. On 07/16, 07/17, 07/18 and 07/19 and 07/20 there was 2 PCT’s for a census of 21. According to the facility’s staffing matrix the PCT to patient ratio was supposed to be 1:9. The PCT’s were working over this ratio. On 07/08, 07/11, 07/12, 07/13, 07/17, and 07/18 there was a LVN (licensed vocational nurse) working according to the facility’s staffing sheets. The facility’s total census for the 3rd and 4th floors for 07/04-07/20 for the 7:00 p.m.-7:00 a.m. shift ranged from 30 -42 patients. According to the facility’s staffing matrix there should have been 5-7 RN’s working. On 07/18 and 07/19 the total patient census for 3rd and 4th floors was 42. The staffing matrix called for 7 RN’s, but the facility used 4 RN’s and 2 LVN’s (short 3 RN’s) on 07/18 and 5 RN’s and 1 LVN on 07/19 (short 2 RN’s). There was no allowance for interchanging RN’s with LVN’s according to the facility’s staffing matrix. 4th FLOOR 7:00 a.m.-7:00 p.m. shift On 07/04, and 07/17 there was 2 PCT’s for a census of 18. On 07/05 there was 2 PCT’s for a census of 17. On 07/18 and 07/19 there was 2 PCT’s for a census of 21. On 07/20 and 07/21 there was 2 PCT’s for a census of 20. According to the facility’s staffing matrix the PCT to patient ratio. was supposed to be 1:9. The PCT’s were working over this ratio. On 07/04 (census 18), 07/05(census 17), 07/06(census 15) and 07/20(census 20) there was two RN’s and one LVN. On 07/07(census 14), 07/10(census 13),07/11(census 13), 07/12(census 13), 07/13 (census 13), 07/15 (census 14) there was one RN and one LVN. The facility’s total census for the 3rd and 4th floors for 07/04-07/21 for the 7:00 a.m.-7:00 p.m. shift ranged from 30 -42 patients. According to the facility’s staffing matrix there should have been 5-7 RN’s. On 07/18 and 07/19 the total patient census for both floors were 42. The staffing matrix called for 7 RN’s, but the facility used 5 RN’s and 1 LVN. The facility was 2 RN’s short. There was no allowance for interchanging RN’s with LVN’s according to the facility’s staffing matrix. 7:00 p.m.-7:00 a.m. shift On 07/04(census 17), 07/05(census 15), 07/06(census 14) and 07/14(census 14) there was 1 PCT. According to the facility’s matrix the PCT to patient ratio was supposed to be 1:9. The PCT’s were working over this ratio. On 07/04, 07/05, 07/06, 07/11, 07/12, 07/13, 07/18, 07/19, and 07/20 there was a LVN (licensed vocational nurse) working on the unit. On 07/11(census 13), 07/12(census 13), 07/13 (census 13) there was one RN and one LVN. The facility’s total census for both floors for 07/04-07/20 for the 7:00 p.m.-7:00 a.m. shift ranged from 30 -42 patients. According to the facility’s staffing matrix there should have been 5-7 RN’s. On 07/18 and 07/19 the total patient census for both floors were 42. The staffing matrix called for 7 RN’s, but the facility used 4 RN’s and 2 LVN’s on 07/18 (short 3 RN’s) and 5 RN’s and 1 LVN on 07/19 (short 2 RN’s). There was no allowance for interchanging RN’s with LVN’s according to the facility’s staffing matrix. Review of the facility’s staffing matrix revealed no method for determining patient acuity. During an interview on 07/21/2025 after 2:21 p.m., Staff #3 confirmed the staffing numbers and said there was no method for using patient acuity. Staff #3 said they used to have a method in the past. Staff #3 said that she does not really use the staffing matrix anyway because she knows the numbers. Review of the facility’s named “Staffing Plan-NS “dated with an effective date of 10/05/2022 revealed the following: “ ...8) The plan is based on the following nursing principles and regulatory requirements: ...b) There is an adequate number of RNs, LVNs and other personnel to provide safe nursing care to the patients. c) There is an immediate availability of an RN at all times or bedside care of a patient. d) An RN supervises and evaluates nursing care for each patient. e) An RN assigns the nursing care other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competencies of the nursing staff available. f) The charge nurse is available to the LVN for patient care needs beyond the scope of LVN practice, unless otherwise indicated on the assignment sheet ... 9)The staffing for each unit is based on several critical factors: a) Patient characteristics and number of patients b) Acuity level of the patients c)Variability of patient care across the unit d) Scope of services provided by each unit e) Nursing staff competency, experience, and other pertinent factors f) Unit and shift activity ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 10135 Based on observation, interview and record review, the facility failed to ensure nurses evaluated and provided pressure sore treatment for 1 (Patient #3) of 5 (Patient #’s 2,3,5,7 and 8) patients on the sample that were reviewed for pressure sores. The facility failed to: A. Ensure thorough skin assessments with measurements were documented on Patient #3. B. Ensure physician orders were obtained for treatments to pressure sores on Patient #3. C. Ensure timely incontinent care and preventative cushioning were provided to Patient #3 who was at high risk for skin breakdown. This deficient practice had the likelihood to cause harm to all patients at risk or with pressure sores on both rehab units. Findings include: Review of the record of Patient #3 revealed he was an 85-year-old male was admitted to the rehabilitation unit on 07/18/2025. Review of a physician’s history and physical dated 07/18/2025 revealed Patient #3 was status post open reduction internal fixation of the (right femur). Patient #3 had a history of diagnoses which included asthma, diabetes mellitus, hypertension, and non-pressure chronic ulcer of the foot. Review of a Braden scale assessment (pressure sore risk tool) dated 07/18/2025 at 4:24 p.m. revealed Patient #3 had a score of 16 (meaning at risk for pressure sore injury). Patient #3 was assessed as being chair fast, rarely moist, very limited mobility, adequate nutrition, and had the potential for problems with friction/shear. Some of the interventions listed were to reposition every 1 hour while in the chair and to apply a foam dressing to the sacrum. The first skin assessment pictures taken by nursing were on 07/18/2025 at 8:59 p.m. which noted Patient #3 had skin breakdown on the right buttock. There were two open pink sores and the surrounding skin was macerated in appearance. There was no assessment of measurements of the size of the sores. There was documentation in the physician’s history and physical notes dated 07/18/2025 revealing that the photos had been reviewed. The plan was to continue to monitor skin integrity and apply waffle mattress. A Braden scale assessment dated 07/19/2025 at 10 p.m. revealed Patient #3 had a score of 14 (meaning high risk) and was assessed as being occasionally moist and probably had inadequate nutrition. Some of the interventions were to encourage frequent small weight shifts every 15 minutes while in the chair. To keep skin folds clean and dry (skin barrier products) to protect skin from incontinence. Review of the record revealed no physician orders for treatments to sores on the buttock or the waffle mattress from 07/18-21/2025. An order for a waffle cushion was written on 07/21/2025 at 11:50 a.m. by Staff #17 (3 days later). During an observation on 07/22/2025 after 8:58 a.m., Patient care technician (PCT) #’s 11 and 16 were observed to turn Patient #3 to place him on a bedpan. Patient #3 had a foam dressing over his coccyx/sacral area which was dated 07/19/2025 (3 days ago). Patient #3 had already had a bowel movement. PCT#16 removed the dressing, and it was noted to be soiled with feces underneath it. Patient #3 was observed to have dried flakes of feces to his buttock. PCT #16 was unable to get the feces off with the wet wipes. She had to wet a washcloth to remove the dried feces. Patient #3 was observed to have a pressure sore to the sacral area which had purple tissue with the surrounding tissue being beet red in color. The first physician’s order was dated 07/22/2025 for treatments involving the sacral sore. The following was written: “Wound dressing Sacral Area. Clean with soap and water or no-rinse foam, pat dry, apply skin protectant, cover with sacral foam for protection. If frequent incontinence, discontinue sacral foam for protection and apply zinc barrier BID ...” During an interview on 07/22/2025 at 12:40 p.m., Staff #17 said that he had not received a wound consult on Patient #3. Staff #17 said he had just gotten a treatment order for the sacrum today while he was looking through the chart. No one had really told him anything about what was going on with the sore. During an observation on 07/22/2025 at 3:21 p.m., Staff #’s 17 and 23 provided a treatment, took photos, and took measurements of the sacral pressure sore. The purple deep tissue injury was measured as being 1.5 x 1.0 centimeters and surrounding reddened skin was 3 centimeters in length. During an interview on 07/22/2025 at 3:41 p.m, Staff #17 showed the surveyor the type of foam cushion Patient #3 currently had in his wheelchair. Staff #17 said he was going to switch out the cushion to a waffle cushion. Review of the facility’s policy named “Skin Care and Pressure Wound-NS-MKT” dated 07/03/2024 revealed some of the following: “1)Comprehensive Assessment ... ...c) Subsequent assessment i)After admission, skin/wound assessment to be performed with each shift change, change in patient condition, and upon transfer to another inpatient nursing unit. ii) If dressing is applied to prevent a wound, assess skin under dressing once every shift. iii) If dressing is applied to treat or protect a wound, assess skin under the dressing based on the wound care team’s or provider’s recommendation. If no recommendation exists, change the dressing every 7 days, or per manufacturer’s guidelines. 3)Interventions b) Support surface (i.e. waffle overlay, turning position system, etc.) use should be considered based on their Braden score ... 4)Photography a) A photograph of a wound shall include a measurement guide, if available, the patient’s information (i.e. sticker), location of the wound, date/time of photo, and the clinician’s initials.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to follow and modify the plan of care on 1 of 10 sampled patients (Patient #3). The facility failed to ensure pain medication was administered timely, location of pain was documented and the plan was modified to address the pain severity. This deficient practice had the likelihood to cause harm to all patient experiencing pain on the units. Findings include: Review of the record of Patient #3 revealed he was an 85-year-old male was admitted to the rehabilitation unit on 07/18/2025. Review of a physician’s history and physical dated 07/18/2025 revealed Patient #3 was status post open reduction internal fixation of the (right femur). Patient #3 had a history of diagnoses which included asthma, diabetes mellitus, hypertension, encephalopathy, dementia and non-pressure chronic ulcer of the foot. Review of physician orders revealed Patient #3 had the following for prn (whenever needed) pain medication: Oxycodone immediate release tablet 5mg (milligrams) one every 6 hours prn (whenever needed) moderate pain (4-6) Tylenol #3 300/30 mgs one tablet every one every 6 hours prn (whenever needed) moderate pain (4-6) There were no parameters to address the pain levels less than 4 and those above a level 6. Review of nursing notes revealed the following: On 07/18/2025 at 2:30 p.m. Patient #3 had a severe pain level of 7 and there was no documentation of where the pain was. Over two hours later at 4:43 p.m. Patient #3 was given the Oxycodone 5 milligrams. According to the physician’s order the Oxycodone was for pain levels from 4-6. On 07/20/2025 at 10:09 p.m. Patient #3 had a severe pain level of 8 in the right hip. Patient #3 was given the Oxycodone 5 milligrams at this time. According to the physician’s order the Oxycodone was for pain levels from 4-6. On 07/21/2025 at 12:55 p.m. Patient #3 had a pain level of 10 leg pain while in therapy. There was documentation in therapy notes that was signed off at 3:47 p.m. that Patient #3 had acute leg pain of 10 and was unable to describe it due to advanced dementia. Treatment was limited due to agitation and Patient #3 was limited by pain. At 7:39 p.m. (over 6 hours later) Patient #3 had a pain level of 6 and he was given Oxycodone. During an interview on 07/22/2025 after 10:00 a.m., Staff #3 confirmed the pain levels, medication administration and documentation. Review of the facility’s policy named “Pain Management-NS-MKT” dated 02/07/2025 revealed the following: Procedure: 1) Orders for management of pain will be based on the patient diagnosis, assessment and/or reassessment ... 2)The assessment and reassessment will take into account the individual patient’s response to treatments, both physiologically and emotionally. 3) The plan of care will be initiated, reviewed and modified as indicated .... ...5)Nursing Staff.. ...c.If pain is present, the initial physical assessment should include a comprehensive pain assessment based on patient self-report. Factors may include, but are not limited to, the following parameters: i) Location-point to the body part affected ... ...iv) Based upon observations and collaboration with physician, pain medication will be administered appropriately ...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure memorandums of transfers (MOT’s) were retained in the clinical record and accessible for review by the state regulatory agency when requested in 2 of 10 sampled records (Patient #’s 1 and 6). This deficient practice had the likelihood to affect all patients who were transferred to another facility. Findings include: Patient #1 Review of a physician’s history and physical dated 07/12/2025 revealed Patient #1 was a 92-year- old patient was admitted into the rehab hospital on 07/12/2025. Patient #1 had diagnoses which included hypertension, obstructive sleep apnea and bladder cancer. Review of physician orders dated 07/22/2025 revealed a notation to “please send pt to ER (emergency room) for urinary retention, malfunctioning foley.” Review of nurses’ notes dated 07/22/2025 at 10:12 a.m. revealed EMS was called. Patient #6 Review of a physician’s history and physical dated 06/17/2025 revealed Patient #6 was admitted into the rehab hospital on 06/17/2025. Patient #6 had diagnoses which included thoracic and lumbar posterior fusions, atrial fibrillation, congestive heart failure, hypertension and coronary heart disease. According to nurses’ notes dated 06/19/2025 at 10:02 a.m., Patient #6 complained of chest pain. At 10:10 a.m. an EKG (electrocardiogram) showed Patient #6 had atrial flutter and was sent to the emergency room. According to the receiving hospital ‘s triage notes that were signed off at 11:08 a.m. revealed that Patient #6 arrived via EMS (emergency medical services) with complaints of chest pain that began at 9:45 a.m. The patient was given aspirin in route and was from the rehab. Review of a patient transfer list from 05/02/2025 to 07/18/2025 revealed there were a total of 33 transfer during this timeframe. During an interview on 07/22/2025 after 10:00 a.m., Staff #3 said they did not have the Memorandum of transfers (MOTs) on the patients. Staff #3 said they complete the forms, but do not keep copies on the record. They send the forms to the hospital the patient is being transferred to. The only way they see the forms again is if the patient is sent back to their facility. Review of the facility’s policy named “Emergency Discharge or Transfer of Patient” dated 02/17/2023 revealed the following: “..g) Complete the Memorandum of Transfer-UT Health East Texas-MKT(MOT). The original is sent to the receiving facility; a copy is retained in the patient “medical record. If the patient is transported prior to the Transfer Form being completed, it must be faxed as soon as possible...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 10135 Based on observations and interview, the facility failed to ensure and effective infection control program where staff techniques were implemented to prevent cross contamination on 2 of 10 sampled patients (Patient #’s 3 and 4). The facility failed to: A.) ensure staff removed soiled gloves after cleaning incisions and a pressure sore on Patient #3. B.) ensure staff therapy staff followed the facility’s infection control policy when providing care for Patient #4 who was on contact isolation. This deficient practice had the likelihood to cause harm to all patients on the rehab floors. Findings include: Patient #3 Review of the record of Patient #3 revealed he was an 85-year-old male was admitted to the rehabilitation unit on 07/18/2025. Review of a physician’s history and physical dated 07/18/2025 revealed Patient #3 was status post open reduction internal fixation of the (right femur). Patient #3 had a history of diagnoses which included asthma, diabetes mellitus, hypertension, and non-pressure chronic ulcer of the foot. During an observation on 07/22/2025 at 3:21 p.m., Staff #’s 17 and 23 provided a treatment to incisions and a pressure sore on Patient #3. Staff #23 was observed to cleanse two incision lines. Without removing her gloves Staff #23 reached into her uniform pocket and removed scissors. Staff #23 took the scissors and cut her clean dressings and applied them over the incision sites. Staff #23 then went inside her pocket for a sharpie and dated the dressing she was going to place over the sacral pressure sore. Patient #4 Review of the record of Patient #4 revealed he was a 68-year-old female was admitted to the rehabilitation unit on 07/14/2025. Review of a physician’s history and physical dated 07/14/2025 revealed Patient #4 had a history of diagnoses which included diabetes mellitus, hypertension, and atrial fibrillation. There was documentation in the history and physical which revealed that Patient #4 had urine cultures dated 07/05/2025 which were positive for the bacteria infection extended -spectrum beta -lactamases (ESBL) and Enterococcus faecalis. According to a physician’s order dated 07/14/2025 Patient #4 was to be placed in contact isolation. During an observation on 07/21/2025 after 11:34 a.m., Staff #12 assisted Patient #4 to ambulate around the therapy room. Patient #4 used a walker and Staff #12 walked behind her pushing a wheelchair. Staff #12 had on an isolation gown and gloves and Patient #4 had on a hospital gown over her clothes. There were 4 other patients in the therapy room. At 11:55 a.m. Staff #12 left the walker in the room and failed to sanitize it first. Staff #12 pushed Patient #4 in her wheelchair out of the therapy room, down the hallway and to her room. There was a sign on the Patient #4’s doorframe to her room that read “CONTACT PRECAUTIONS STOP BEFORE ENTERING.” The required precautions listed on the sign were to clean hands with alcohol or soap and water before and after contact with patient or surfaces. During an interview on 07/21/2024 Staff #12 said that Patient #4 was on contact isolation for ESBL in her urine. Staff #12 said that the therapy staff and the patient were both supposed to wear gowns while the patient is in therapy. During an observation on 07/21/2025 at 12:02 p.m., Staff #12 went back to the therapy room, donned gloves and cleaned the walker off with sanitizing wipes. Staff #12 took the same wipes and went over to the ramp that Patient #4 used in the therapy room and wiped the ramp. The ramp had anti-slip adhesives strips on it and the surface was not sanitizable. Staff #12 cross contaminated the surface by using the same wipe that was used to sanitize the walker. During an observation on 07/22/2025 at 9:32 a.m., an unidentified therapy staff member was observed coming out of Patient #4’s bathroom. The unidentified therapy staff was pushing Patient #4 in her wheelchair, and he had on PPE. Patient #4 was assisted out of the room and taken down to the therapy room. Patient #4 did not have on a gown covering her clothes. The unidentified therapy staff member still had on the same PPE gown and gloves he had on while in the room. The unidentified staff member started working with Patient #4 at one of the therapy stations. Another therapy staff member got a gown and handed the unidentified staff member a gown to place on Patient #4. Review of a facility’s policy named “Patient Isolation Policy -IC-MKT” dated 05/22/2024 revealed the following: “...Personal protective equipment- used when the nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur. 1) Gloves-wear gloves appropriate to task, such as touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and non-intact skin. a) Remove gloves after contact with a patient and/or the surrounding environment using proper techniques to prevent hand contamination ... ...Contact Precautions Intended to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact with the patient or the patient’s environment ... ...PPE (Personal Protective Equipment) The following PPE to be donned before entering the room and doffed before leaving the room: 1) Gloves 2) Gowns 3) Other PPE as needed according to Standard Precautions ... ...The therapy staff will utilize the following steps: 1) Therapy staff will perform hand hygiene and don PPE before entering the room. 2) Place a clean hospital gown on the patient as a barrier. 3) Remove the PPE before leaving the patient isolation room. 4) Both staff and patient perform hand hygiene before leaving the room. 5) Transport/ambulate the patient to the gym or while outside of the room. 6) In the gym, the therapist will don a new isolation gown and gloves. 7) Upon returning to the room, the patient and staff will perform hand hygiene. 8) Staff will don PPE before entering the room. 9) Staff will doff PPE and perform hand hygiene before leaving the room. The patient will use a dedicated mat, not to be used by others until the isolation patient is completed therapy and the mat and any equipment used have been disinfected with an approved disinfectant. The patient may contact only those materials that can be disinfected ...””