**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were observed, and the facility policies and procedures related to infection control were implemented when: 1. The facility did not report to the California Department of Public Health (CDPH- state agency responsible for public health in California, enforcing some of the laws affecting healthcare facilities) of a COVID 19 (coronavirus - a contagious respiratory infection) outbreak when the facility had one COVID-19 positive staff and four COVID-19 positive residents on February 5, 2025. This failure resulted in the state agency being unaware of the presence of a COVID-19 outbreak in the facility and had the potential of delayed implementation of infection control measures to address COVID-19; and 2. The facility did not implement Enhanced Barrier Precautions (EBP - a strategy recommending the use of gown and gloves during provision of high-contact resident care activities (dressing, bathing, transferring, providing hygiene, linen change, assisting with toileting, indwelling device [a medical device that remains inside the body] care, and wound care) to the residents with wounds, indwelling devices, and colonized (the presence of microorganisms [such as bacteria, viruses, or fungi] on or in a person's body without causing any apparent symptoms or disease) MDRO [multidrug resistant organisms -germ that is resistant to many antibiotics] infection to reduce the spread of MDRO transmission), according to Centers for Disease and Prevention Control (CDC) guidelines, for 17 of 21 residents (17 residents had indwelling medical devices [Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21], five of 17 residents [Residents 5, 15, 17, 18, 21] had colonized (the presence and multiplication of microorganisms (such as bacteria, viruses, or fungi) on or in a body surface without causing any apparent signs or symptoms of infection) MDRO infection, and one of 17 residents (Resident 11) had pressure injuries [bed sores]). In addition, the facility did not have a policy and procedure with the use of EBP. On February 20, 2025, at 8 p.m., the Director of Nursing (DON) and the Quality Assurance Officer (QA) were verbally notified of the Immediate Jeopardy (IJ - situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure of not implementing Enhanced Barrier Precautions while providing high contact care activities to 17 residents (Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21) with indwelling devices. The facility's failure to implement EBP during provision of high contact resident care activities had the potential to result in the spread of MDROs to the immunocompromised residents, and could cause serious harm, and aggravate the already vulnerable and compromised health conditions of the residents. On February 21, 2025, at 4:38 p.m., the QA and the DON presented an acceptable removal plan which included the following: - Members of the Governing Board and MEC (Medical Executive Committee) were notified immediately of the findings by the COO (Chief Operating Officer); - On February 20, 2025, the DON identified all residents with colonized MDROs, those at increased risk to acquire MDRO infection, and those that require high contact care activities for which EBP should be used; - On February 21, 2025, the DON validated the facility had appropriate and adequate levels of PPE (Personal Protective Equipment - protective clothing or equipment worn by healthcare workers to minimize exposure to hazards and prevent illnesses) to use for EBP. The DON contacted central supply to ensure levels were justified and supplies were available at all times; - On February 21, 2025, all residents currently on the unit were evaluated by the DON to ensure no adverse effects occurred. EBP was implemented immediately for all residents if applicable by the DON/designee; - On February 21, 2025, appropriate signage for EBP was created by the DON and placed by the room entrances of residents for whom EBP should be used to aid in identifying and reminding staff to use EBP when providing high contact care activities to the residents; - On February 21, 2025, the DON rounded on all resident's' rooms to ensure the appropriate signage for EBP is in place as per facility policy. Any missing signage was immediately placed in applicable rooms; - On February 21, 2025, the Medical Director (MD) of the subacute unit was notified of the IJ and was advised of the findings. The MD will continue to collaborate with the leadership team to create and implement the appropriate infection control measure; - On February 21, 2025, the resident and/or resident representatives of all residents impacted by the deficiency were notified of the incident via phone by the DON/designee; - On February 21, 2025, the DON/RN Charge Nurse immediately started staff education on EBP and hand hygiene using 1:1 education and group education during huddles. The staff will receive the education before the start of their next shift; - On February 21, 2025, providers for the residents impacted by this deficiency were contacted and orders obtained to include the use of EBP. The care plans of the affected residents impacted by this deficiency were updated by the DON/RN to include the use EBP; - On February 21, 2025, the DON reviewed the policy on EBP and revised it to ensure compliance with current regulations and best practices. The policy reviewed and approved by the Medical Director of the subacute unit and Medical Director of infection control; - On February 21, 2025, all staff present were educated on the revised EBP policy by the DON/designee. Staff not present will be educated on the revised policy before the start of their next shift. All staff will be educated to the policy by February 23, 2025. On February 25, 2024, at 4:26 p.m., the immediate jeopardy was removed in the presence of the DON, upon onsite verification of the implementation of the plan of actions. Findings: On February 20, 2025, at 9:05 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding infection control. 1.On February 20, 2025, at 12:53 p.m., during an interview with the Infection Preventionist (IP), the IP stated there was a COVID-19 outbreak in the facility which began on February 5, 2025, with one COVID-19 positive staff and four COVID-19 positive residents. On February 20, 2025, a review of the facility's COVID-19-line listing indicated Residents 2, 14, 16, and 17, and Certified Nursing Assistant (CNA) 7 were tested positive on February 5, 2025. The IP stated she reported the outbreak to the county public health officer but not to CDPH. The IP further stated the COVID-19 outbreak should have been reported to the CPDH. On February 21, 2025, Residents 2, 14, 16, and 17 records were reviewed. The record review indicated the following: a. Resident 2 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (lung failure). Resident 2's Progress Note Inquiry, dated February 5, 2025, at 11:04 p.m., indicated, .Resident tested positive for Covid . b. Resident 14 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. Resident 14's Progress Note Inquiry, dated February 5, 2025, at 10:51 p.m., indicated, .Resident tested positive for Covid . c. Resident 16 was admitted to the facility on [DATE], with diagnoses which included kidney failure. Resident 16's Progress Note Inquiry, dated February 5, 2025, at 9:24 p.m., indicated, .Resident tested positive for Covid . d. Resident 17 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. Resident 17's Progress Note Inquiry, dated February 5, 2025, at 9:59 p.m., indicated, .Resident tested positive for Covid . A review of the facility's policy and procedure titled, Outbreak Investigation and Management, revised December 2022, indicated, .to control the spread of infection or disease and to identify factors that contributed to the outbreak in order to develop and implement measures to prevent similar outbreaks in the future .The Infection Prevention Committee (IPC) shall have the responsibility for investigating outbreaks .Any suspected outbreak shall be reported to the (name of county) Department of Public Health and the appropriate Public Health licensing and certification department . A review of AFL (All Facilities Letter- a CDPH communication letter to all facility types including Skilled Nursing Facilities [Nursing Homes]) 23-08, dated January 18, 2023, indicated, .This AFL reminds providers of the requirements to report outbreaks and unusual infectious disease occurrences to the local public health officer and the California Department of Public Health (CDPH) and provides definitions and updated examples of reportable incidents .Health facilities licensed by CDPH Licensing and Certification (L&C) are required to report outbreaks (occurrence of cases of a disease or condition above the expected or baseline level, usually over a given period of time, in a geographic area or facility, or in a specific population group) and unusual infectious disease occurrences to the local public health officer and their respective District Office (DO) .Examples of Reportable Incidents .Facility outbreak of COVID-19, influenza (lung infection caused by influenza viruses), pneumonia (bacterial lung infection), other respiratory viral pathogen (e.g., respiratory syncytial virus), or gastroenteritis (e.g., norovirus- virus causing abdominal symptoms) . A review of the Council for Outbreak Response: Healthcare-Associated Infections and Antimicrobial-Resistant Pathogens (CORHA) and the Council of State and Territorial Epidemiologists' (CSTE) article titled Proposed Investigation/Reporting Thresholds and Outbreak Definitions for COVID-19 in Healthcare Settings, dated January 2, 2024, indicated thresholds for reporting to Public Health for Long Term Care Facilities (LTCFs- includes nursing homes) is two or more cases of probable or confirmed COVID-19 among residents identified within seven days, OR two or more cases of suspect, probable, or confirmed COVID-19 among health care providers (facility staff) and one or more case of probable or confirmed COVID-19 among residents . 2. On February 20, 2025, beginning at 9:50 a.m., an observation of the facility from Rooms 401 to 410 was conducted. The following were observed: - Residents 5 and 6 were both observed to have tracheostomies (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). Respiratory Therapist 1 was observed providing respiratory care at bedside to Resident 5 while wearing a surgical mask and gloves, no gown was in use. There was no EBP sign outside Residents 5 and 6's room; - Concurrently, one female staff was observed moving around Resident 6's bed through the privacy curtain. After rendering care, the female staff drew the curtain halfway open and upon coming through the curtains, staff was observed not wearing a mask or gown, and proceeded to remove and discard her gloves in the trash can; - Residents 1, 2, 3, and 13's rooms were observed to have a sign outside the door indicating Contact Precautions (infection control measures used to prevent the spread of infectious diseases that are transmitted through direct contact with the patient or their contaminated environment requiring use of PPE such as mask, gown, gloves), and instructions to wear specific PPE. - There was no sign for EBP by the door of Residents 4, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21's rooms. - Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21, were observed to have indwelling devices such as tracheostomies and gastrostomy (GT - tube that is inserted into the stomach through the abdominal wall to provide nutrition, hydration, or medicine). Residents 11 and 15 had an indwelling catheter (a thin, flexible tube inserted into the urinary bladder to collect and drain urine). On February 20, 2025, at 10:03 a.m., during an interview with the IP, she stated the following residents were placed on contact precautions due to the presence of MDRO infection: - Resident 1; CRPA (carbapenem-resistant pseudomonas aeruginosa - a type of bacterial infection that is resistant to many antibiotics) in the sputum; - Resident 2; CRPA in the urine; - Resident 3; CRPA in the wound; - Resident 13; MRSA (methicillin-resistant staphylococcus aureus - a type of bacteria resistant to several antibiotics) in the wound. The IP further stated there were no residents placed on EBP. On February 20, 2025, at 11:01 a.m., Certified Nursing Assistant (CNA)1 was interviewed. CNA 1 stated she did not know what EBP was and had never heard of it before. On February 20, 2025, at 11:18 a.m., CNA 2 was interviewed. CNA 2 stated she had no awareness of what EBP was. On February 20,2025, at 12:53 p.m., a follow up interview was conducted with the IP. The IP stated there were no residents in the facility who were placed on EBP. On February 20, 2025, at 3:21 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated he was not aware what EBP was and had never cared for any residents who were placed on EBP in the unit. LVN 1 further stated he never received any in-services regarding EBP, but always wore gloves and masks for any kind of patient care since all the residents were trached (had tracheostomies). LVN 1 could not articulate what type of PPEs were to be used when a resident was placed on EBP. On February 20, 2025, beginning at 4:10 p.m., the following were observed: - There were still no EBP signs by the door of the rooms not placed on contact isolation; - LVN 2 entered Residents 17 and 18's room and provided care to the residents. LVN 2 was observed wearing only gloves, did not put on a gown or mask prior to entering and while providing care to Residents 17 and 18; - CNA 3 entered Residents 17 and 18's room wearing a mask, but did not put on any gown or gloves prior to entering and was observed to change the linens of the residents; - At 4:34 p.m., CNA 2 entered Residents 17 and 18's room and observed wearing gloves, but did not put on any gown or mask while assisting CNA 3 with resident care and turning the residents. On February 20, 2025, at 4:35 p.m., CNA 3 was interviewed. CNA 3 stated the facility only used EBP during COVID-19 outbreaks. On February 20, 2025, at 4:57 p.m., LVN 2 was interviewed. LVN 2 stated she was not sure what EBP referred to and had never heard of EBP. On February 20, 2025, at 5:13 p.m., the IP was interviewed. The IP stated the staff should use gloves or gowns when providing care to residents. The IP further stated gowns were optional when doing perineal care or turning a patient when staff needed to create a barrier between staff and the resident. The IP stated they did not put EBP signs on the resident's door because all residents should be using EBP. On February 20, 2025, at 5:44 p.m., the DON was interviewed. The DON stated EBP was a new practice, and not a lot of people knew about it yet, and EBP was not being practiced at the facility. The DON stated the staff was to wear the appropriate PPEs, such as gown, gloves, when providing care to residents placed on EBP. The DON stated, the hospital doesn't understand it, and the facility staff would not know what EBP was because she had not trained them on it. The DON stated if EBP or other infection precautions were not to be followed, there would be a potential risk for spread of infections such as MDROs among the residents. The DON further stated the facility did not have a policy on EBP. On February 20, 2025, a review of residents' records indicated the following; a. A review of Resident 4's Patient Information, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included sepsis (body's extreme response to an infection, a life-threatening medical emergency). A review of Resident 4's History and Physical, dated February 6, 2025, indicated PEG placement (percutaneous endoscopic gastrostomy- a type of feeding tube), tracheostomy, and right frontal ventricular drain (a catheter inserted into the brain through the skull to monitor and drain cerebrospinal fluid) placement. Further review of Resident 4's record did not include a physician's order and care plan for Resident 4 to be placed on EBP. b. A review of Resident 5's Patient Information, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included chronic (persisting for a long time) respiratory failure. A review of Resident 5's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube/GT. A review of Resident 5's Patient Care Summary, included physician's orders for tracheostomy therapy and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 5's record did not include a physician's order and care plan for Resident 5 to be placed on EBP. c. A review of Resident 6's Patient Information, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included respiratory failure and anoxic (oxygen deficient) brain injury. A review of Resident 6's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 6's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment. The orders also included care and maintenance orders for the feeding tube. Further review of Resident 6's record did not include a physician's order and care plan for Resident 6 to be placed on EBP. d. A review of Resident 7's Patient Information, indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure s/p (status post) trach (tracheostomy) and PEG. A review of Resident 7's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 7's Patient Care Summary, dated January 31, 2025, included a physician's orders for tracheostomy care and treatment and nutritional formula feeding via J-tube (a type of GT surgically inserted into the small intestine to deliver food and medicine), as well as care and maintenance orders for the feeding tube. Further review of Resident 7's record did not include a physician's order and care plan for Resident 7 to be placed on EBP. e. A review of Resident 8's Patient Information, indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. A review of Resident 8's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 8's Patient Care Summary, dated January 31, 2025, included a physician's orders for tracheostomy care and treatment and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 8's record did not include a physician's order and care plan for Resident 8 to be placed on EBP. f. A review of Resident 9's Patient Information, indicated Resident 9 was admitted to the facility on [DATE], with diagnoses which included cardiopulmonary arrest (heart attack). A review of Resident 9's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 9's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 9's record did not include a physician's order and care plan for Resident 9 to be placed on EBP. g. A review of Resident 10's Patient Information, indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. A review of Resident 10's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 10's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment and nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 10's record did not include a physician's order and care plan for Resident 10 to be placed on EBP. h. A review of Resident 11's Patient Information, indicated Resident 11 was admitted to the facility on [DATE], with diagnoses which included acute (begins and worsens quickly) respiratory failure and acute encephalopathy (group of conditions that cause brain dysfunction). A review of Resident 11's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 11's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care, urinary catheter care and treatment, and nutritional formula feeding via GT. Further review of Resident 11's record did not include a physician's order and care plan for Resident 11 to be placed on EBP. i. A review of Resident 12's Patient Information, indicated Resident 12 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure, cardiac arrest, and anoxic brain injury. A review of Resident 12's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 12's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, as well as care and maintenance orders for the feeding tube. Further review of Resident 12's record did not include a physician's order and care plan for Resident 12 to be placed on EBP. j. A review of Resident 14's Patient Information, indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included respiratory failure and chronic heart failure. A review of Resident 14's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 14's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment and maintenance orders for the feeding tube. Further review of Resident 14's record did not include a physician's order and care plan for Resident 14 to be placed on EBP. k. A review of Resident 15's Patient Information, indicated Resident 15 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, and anoxic quadriplegia (paralysis of all four limbs). A review of Resident 15's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 15's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, care and maintenance orders for the feeding tube, and urinary catheter change. Further review of Resident 15's record did not include a physician's order and care plan for Resident 15 to be placed on EBP. l. A review of Resident 16's Patient Information, indicated Resident 16 was admitted to the facility on [DATE], with diagnoses which included kidney failure. A review of Resident 16's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 16's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, and care and maintenance orders for the feeding tube. Further review of Resident 16's record did not include a physician's order and care plan for Resident 16 to be placed on EBP. m. A review of Resident 16's Patient Information, indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure and acute encephalopathy. A review of Resident 17's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube/GT. A review of Resident 17's Patient Care Summary, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, and care and maintenance orders for the feeding tube. Further review of Resident 17's record did not include a physician's order and care plan for Resident 17 to be placed on EBP. n. A review of Resident 18's Patient Information, indicated Resident 18 was admitted to the facility on [DATE]. A review of Resident 18's History and Physical, dated May 29, 2024, indicated the physician's impression (clinical assessment) of anoxic brain injury, decubiti (pressure injury-bed sore), GT, and tracheostomy. A review of Resident 18's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 18's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via feeding tube, and care and maintenance orders for the feeding tube. Further review of Resident 18's record did not include a physician's order and care plan for Resident 18 to be placed on EBP. o. A review of Resident 19's Patient Information, indicated Resident 19 was admitted to the facility on [DATE], with diagnoses which included respiratory failure. A review of Resident 19's Patient Medication Profile, dated January 31, 2025, indicated administration of medications via feeding tube. A review of Resident 19's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, and care and maintenance orders for the feeding tube. Further review of Resident 19's record did not include a physician's order and care plan for Resident 19 to be placed on EBP. p. A review of Resident 20's Patient Information, indicated Resident 20 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, sepsis, and pneumonia (bacterial lung infection). A review of Resident 20's History and Physical, dated November 5, 2024, indicated diagnoses of tracheostomy and PEG. A review of Resident 20's Patient Care Summary, dated January 31, 2025, included physician's orders for secretion suctioning and tracheostomy care and treatment, PICC line dressing changes (peripherally inserted central catheter- a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart), nutritional formula feeding via feeding tube, and care and maintenance orders for the feeding tube. Further review of Resident 20's record did not include a physician's order and care plan for Resident 20 to be placed on EBP. q. A review of Resident 21's Patient Information, indicated Resident 21 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure. A review of Resident 21's History and Physical, dated September 1, 2020, indicated secondary diagnoses of chronic tracheostomy and PEG status. A review of Resident 21's Patient Care Summary, dated January 31, 2025, included physician's orders for tracheostomy care and treatment, nutritional formula feeding via GT, and maintenance orders for the feeding tube. Further review of Resident 21's record did not include a physician's order and care plan for Resident 21 to be placed on EBP. A review of the facility's policy and procedure titled, .Category: Infection Control .Enhanced Standard Precautions (ESP) for Long-Term Care Facilities, created April 2016, indicated the absence of updated guidance regarding Enhanced Barrier Precautions. A review of the CDPH's Enhanced Standard Precautions for Skilled Nursing Facilities (SNF), revised September 2022, indicated, .Since the publication of Enhanced Standard Precautions for Skilled Nursing Facilities, 2019, the epidemiology of multidrug-resistant organisms (MDRO) in California skilled nursing facilities (SNF) has changed considerably, in part due to healthcare challenges related to the COVID-19 pandemic .In addition, large, sustained, regional outbreaks of previously novel or rare MDRO, including Candida auris and NDM-producing Acinetobacter baumannii have occurred in SNF and high-acuity long-term care facilities such as ventilator-equipped skilled nursing facilities .Both C. auris and A. baumannii are easily transmissible among residents and particularly persistent in the healthcare environment; once identified in a healthcare facility, they can be difficult to contain. CDPH has adopted a comprehensive strategy to prevent, contain, and mitigate these MDRO in California SNF and other healthcare settings. Enhanced Standard Precautions (ESP) is a core component of this strategy, both during the prevention and mitigation phases. Increased MDRO prevalence and outbreaks in California highlight the role of ESP as a prevention strategy before transmission and outbreaks occur, as well as a need for new guidance included in this update for transitioning from Contact Precautions to ESP as part of long-term outbreak mitigation and management .To simplify and facilitate implementation of CDPH's ESP, we have consolidated the risk factors for identifying residents at high risk for MDRO colonization and transmission to include unhealed wounds and medical devices, in alignment with CDC's EBP . A review of QSO 23-08-NH (a memorandum from the Centers for Medicare and Medicaid Services' Quality, Safety and Oversight Group), dated March 20,2024, indicated, .Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities (i.e., nursing homes), contributing to substantial resident morbidity and mortality and increased healthcare costs. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs .In 2019, CDC introduced a new approach to the use of personal protective equipment (PPE) called Enhanced Barrier Precautions (EBP) as a strategy in nursing homes to decrease transmission of CDC-targeted and epidemiologically important MDROs when contact precautions do not apply. The approach recommended gown and glove use for certain residents during specific high-[TRUNCATED]