Inadequate COVID-19 Testing and Infection Control Measures
Summary
The facility failed to implement a broad-based COVID-19 testing approach for staff and residents despite being in outbreak status since a staff member tested positive. Initially, only symptomatic individuals, roommates of positive residents, and staff who requested testing were tested. This approach did not align with CDC guidelines, which recommend a broad-based testing approach during outbreaks. As a result, the facility did not initiate broad-based testing until several days after multiple residents across different halls tested positive, leading to a significant number of COVID-19 cases among residents and staff. Additionally, the facility's infection control practices were inadequate, as observed by surveyors. Many staff members failed to wear surgical masks properly, with masks not covering both the mouth and nose, which is essential for source control to prevent transmission. Furthermore, a nurse aide entered a resident's room under transmission-based precautions without wearing the required eye protection. These lapses in infection control measures contributed to the potential for continued transmission of COVID-19 within the facility. The facility's policies and procedures for infection prevention and control did not conform to CDC guidance, particularly regarding outbreak testing and the use of personal protective equipment (PPE). The Infection Preventionist and Director of Nursing were aware of the outbreak but did not implement the necessary measures to control the spread effectively. The facility also failed to initiate the administration of the 2024-2025 COVID-19 vaccinations for residents in a timely manner, further exacerbating the risk of transmission.
Removal Plan
- The Director of Nursing and Infection Preventionist completed broad-based testing on all staff and residents within the facility. The facility will complete testing on all residents and staff twice per week until there is a 14-day interval of no new positive cases.
- The Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator/Infection Preventionist, and the Unit Managers regarding Special Droplet Contact Precautions when a resident tested positive for COVID-19.
- All staff, including medical director and Nurse Practitioner, will perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before exiting the room.
- All staff, including medical director and nurse practitioner will wear a gown when entering the room, remove before exiting the room.
- All staff, including medical director and nurse practitioners, will wear an N95 when entering the room and remove before exiting the room.
- All staff, including the medical director and nurse practitioner will wear eye protection such as a face shield or goggles when entering the room and remove them before exiting the room.
- All staff, including the medical director and nurse practitioner will wear gloves when entering the room and remove them before leaving the room.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding source control to include wearing face mask throughout the building during outbreak status regardless of if they are in a covid positive room or not.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding Special Droplet Contact Precautions when a resident test positive for COVID-19.
- The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift in person.
- The Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly don Personal Protective Equipment.
- The Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly doff Personal Protective Equipment.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly don Personal Protective Equipment with current staff.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly doff Personal Protective Equipment with current staff.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A deficiency occurred when staff failed to follow enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. The resident had severe cognitive impairment, required total assistance with ADLs, and had a care plan and MD orders specifying EBP due to the catheter. An EBP cart with PPE was available outside the room, but during observed catheter care a CNA did not don a gown, despite acknowledging that the resident was supposed to be on EBP. Facility policy required EBP for residents with urinary catheters for the duration of their stay.
A resident with toxic encephalopathy, Parkinson’s disease, and a gastrostomy, who was cognitively impaired and dependent for toileting and dressing, had active orders and a care plan requiring Enhanced Barrier Precautions (EBP) with gown and glove use during high-contact ADL care, toileting, and linen changes. Surveyors observed a CNA repeatedly entering and exiting the resident’s room, which was posted for EBP, without wearing a gown while providing perineal care, toileting assistance, dressing, and changing bed linens. The CNA acknowledged the resident was on EBP, that no PPE supply was available near the room, and that she did not wear a gown, contrary to the facility’s EBP policy requiring gowns and gloves for such high-contact care.
Surveyors identified multiple infection prevention and control failures involving several residents, including a resident with pneumonia and impaired cognition whose soiled linens and used brief were left on the floor during care, and residents with diabetes whose blood glucose checks and insulin administration were performed by LPNs who did not perform hand hygiene and did not properly disinfect shared glucometers between uses. Additional residents receiving oral and nasal medications had their medications prepared and administered by LPNs who did not wash their hands before or after resident contact or before reentering the medication cart. A severely cognitively impaired resident with a chronic sacral wound and an indwelling catheter, care planned for Enhanced Barrier Precautions, received high-contact care from two CNAs who did not don gowns and did not perform hand hygiene while changing briefs, handling catheter tubing and bags, and transferring the resident. The facility also failed to carry out its Legionella Water Management Program, as the Administrator confirmed that required Legionella testing of the water system was either limited to ice machines in one year or not performed at all in the following year, despite the presence of unused rooms with stagnant water.
An LPN failed to clean reusable vital sign equipment between two residents on enhanced barrier precautions, including one on contact precautions for Klebsiella pneumoniae, and reached into a red biohazard bin containing soiled gowns with bare hands after removing PPE. On a resident hallway, a linen cart was left uncovered with clean towels and gowns exposed, and a dirty towel with brown spots was found on top of the clean linen cart, with a bag of soiled items placed directly next to it on the floor. Staff later acknowledged that reusable equipment should be cleaned between residents and that linen carts should remain covered, consistent with facility infection control policies.
The deficiency involves multiple breakdowns in infection prevention and control, including improper handling of soiled linen, failure to follow Enhanced Barrier Precautions (EBP), and lack of an annual TB risk assessment. A resident with incontinence routinely placed saturated soiled laundry on the floor in a room corner, and housekeeping staff added wet soiled items directly to this floor pile before CNAs collected them. Two residents with orders for EBP—one with profound intellectual disabilities and tube feeding, and another with an indwelling urinary catheter and ESBL—received high-contact care such as incontinence care, dressing, transfers, and catheter bag handling from CNAs and an LPN who used gloves but did not don gowns, despite posted EBP signage and available PPE. The facility also lacked documentation of a required annual TB risk assessment for one year, which was confirmed by the IP despite a policy mandating yearly completion.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of enhanced barrier precautions (EBP) for a resident with an indwelling urinary catheter. The resident, admitted with diagnoses including right hip fracture, dementia, insomnia, and anxiety disorder, had a Minimum Data Set assessment indicating severe cognitive impairment and dependence on staff for ADLs. The resident’s care plan documented the presence of an indwelling catheter for skin breakdown and urinary retention, with an intervention specifying that staff were to maintain EBP due to the catheter, and physician orders also directed that the resident be on EBP. During observation, an EBP cart stocked with PPE was present outside the resident’s room, but when a CNA provided catheter care, the CNA did not don a gown as required. In a subsequent interview, the CNA confirmed awareness that the resident was supposed to be on EBP and acknowledged not wearing a gown while providing care. Review of the facility’s Isolation Precautions Process policy showed that EBP was to be used for residents with urinary catheters during their entire stay, which was not followed in this instance.
Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring proper use of personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). The resident was admitted with diagnoses including toxic encephalopathy, Parkinson’s disease, and gastrostomy status, and was documented as moderately cognitively impaired, dependent on staff for toileting and lower body dressing, and frequently incontinent of bowels. The physician’s orders and active care plan required staff to use EBP, including gowns and gloves, during high-contact care activities such as ADL care, toileting, changing briefs, and linen changes due to the presence of a feeding tube. Surveyor observations showed that a CNA repeatedly entered and exited the resident’s room, which had an EBP sign on the door, without wearing a gown while assisting with toileting, perineal care, dressing, and changing bed linens. The CNA confirmed she was providing these high-contact care activities, verified that the resident was on EBP, and acknowledged that she did not wear a gown and that there was no supply of PPE near the room. A clear trash bag in the room contained discarded products but no used gowns. Review of the facility’s EBP policy dated 12/3/25 stated that, at minimum, staff must wear gloves and gowns during high-contact care activities including ADL care, toileting, and showers, which was not followed in this instance.
Widespread Infection Control and Water Management Failures
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices during resident care, medication administration, blood glucose monitoring, and environmental management. For one resident with pneumonia, muscle weakness, impaired cognition, and dependence on staff for toileting, a CNA was observed providing care with the room door open while soiled linens and a used adult brief were left on the floor. The CNA acknowledged that the dirty linens and brief were on the floor and stated she would pick them up after finishing care. The DON later confirmed that dirty linens were not to be placed on the floor and should be put in a bag. For residents with diabetes, staff did not follow hand hygiene and equipment disinfection policies during blood glucose monitoring and insulin administration. One cognitively intact resident with type 2 diabetes and acute kidney failure had an order for twice-daily blood sugar checks. An LPN removed a glucometer from the medication cart, entered the resident’s room, performed a fingerstick blood sugar check without cleaning the glucometer before use, then briefly wiped it with an alcohol pad afterward. The LPN returned the glucometer to the cart without performing hand hygiene before or after the procedure and confirmed that the device was used on multiple residents daily and that she had not cleaned it before use or washed her hands. Another resident with type 2 diabetes and chronic kidney disease, who received daily insulin, had a fingerstick blood sugar check and insulin administration performed by a different LPN who never washed her hands or used hand sanitizer before, between, or after entering and exiting the room. This LPN placed the glucometer on top of the cart, handled multiple insulin pens, administered insulin, then briefly wiped the glucometer for about 12 seconds before returning it to the cart, and confirmed she had not performed hand hygiene and believed this was the correct way to clean the glucometer. These practices did not follow the facility’s handwashing and cleaning/disinfecting policies or the Sani Wipe instructions requiring a two-minute wet time. Additional hand hygiene failures occurred during medication administration for residents with significant functional impairments. One severely cognitively impaired resident with radiculopathy, diabetes, and muscle weakness required assistance with ADLs. An LPN prepared 12 oral medications from the cart without hand hygiene, administered them along with a nasal spray, then returned the nasal spray to the cart without washing her hands before or after resident contact or before reentering the cart. Another cognitively intact resident with Parkinson’s disease and chronic kidney disease, who required ADL assistance, received 10 medications prepared in applesauce by a different LPN who also did not wash her hands before preparing the medications, after administering them, or before accessing the cart again to prepare medications for the next resident. These actions were inconsistent with the facility’s handwashing policy requiring hand hygiene before and after resident care and invasive procedures. The facility also failed to follow Enhanced Barrier Precautions (EBP) for a resident with severe cognitive impairment, a chronic sacral wound, and an indwelling catheter, who was care planned for EBP due to chronic wounds and device use. Two CNAs provided high-contact care, including a brief check and change, emptying the catheter bag, disconnecting and reconnecting catheter tubing, draining urine, dressing the resident, and transferring the resident via mechanical lift, without donning isolation gowns and without performing hand hygiene before, during, or after care. One CNA acknowledged the presence of an EBP sign at the room entrance instructing staff to wear gloves and a gown for high-contact activities such as transferring and device care, and both CNAs confirmed they had not worn gowns or performed hand hygiene. These actions did not comply with the facility’s EBP and handwashing policies. In addition to direct care issues, the facility did not implement its Legionella Water Management Program as written. The Administrator confirmed that in one year the facility only tested ice machines and did not perform required Legionella testing of the broader water system, and in the following year no Legionella testing was completed at all. The Administrator further confirmed that the facility used city water and that, despite contacting the water company, no Legionella testing was performed. The Administrator also acknowledged that there were empty resident rooms with private bathrooms and sinks where water could remain stagnant and that these areas were not tested in either year. These practices did not align with the facility’s Legionella Water Management Program policy, which required identification and monitoring of areas in the water system where Legionella could grow and spread, including storage tanks, water heaters, filters, aerators, showerheads, hoses, misters, humidifiers, and fountains, and required at least annual review of the program.
Failure to Clean Reusable Equipment and Maintain Clean Linen Storage
Penalty
Summary
The deficiency involves failures in infection prevention and control related to reusable equipment cleaning and linen handling. One resident with sepsis, sarcoid myocarditis, an indwelling urinary catheter, and Klebsiella pneumoniae was on enhanced barrier precautions and contact precautions. Another resident with onychogryphosis and moderately impaired cognition was on enhanced barrier precautions due to a suprapubic catheter. During observation, an LPN obtained vital signs, including pulse oximetry, thermometer, and blood pressure measurements, from the first resident and then from another resident without cleaning the reusable equipment between residents. The LPN removed her gown and gloves and, when attempting to dispose of them in a red biohazard bin where the bag had fallen, reached into the bin with bare hands despite multiple dirty gowns being present, and later confirmed she should have worn gloves and cleaned the equipment between residents. Additional observations on the F Hallway showed improper linen storage and proximity of soiled items to clean linen. A three-tier linen cart was observed with its front cover flap left open, exposing all towels and gowns to the air; a CNA confirmed the flap should always be down covering the linen. Later, the housekeeping supervisor observed a dirty white towel with brown spots placed on top of the clean linen cart and a dirty bag on the floor directly next to the linen cart containing gloves and a gown, and confirmed these findings. The DON confirmed that staff should be cleaning all reusable equipment between residents. Policy reviews showed that facility infection control policies required gloves when there is potential contact with blood or body fluids and required that reusable equipment not be used for another resident until appropriately cleaned and reprocessed.
Failure to Follow EBP, Handle Soiled Linen Properly, and Complete Annual TB Risk Assessment
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program related to handling of soiled linen, adherence to Enhanced Barrier Precautions (EBP), and completion of the annual tuberculosis (TB) risk assessment. For one resident with acute and chronic respiratory failure with hypoxia, type 2 diabetes with hyperglycemia, chronic kidney disease stage 3, and mixed bladder incontinence, the resident reported placing soiled laundry on the floor in the corner of the room every day for staff to collect. On one occasion, housekeeping staff also picked up the resident’s wet soiled laundry and placed it directly on the floor in the same corner. A CNA later confirmed the laundry was saturated and had not been previously known to be on the floor, verifying that soiled linen was being stored on the floor of the resident’s room. The facility also failed to follow its own EBP policy for two residents who had orders for EBP. One resident with cerebral palsy, profound intellectual disabilities, seizures, hypertension, and dysphagia had an order for EBP and tube feeding via Isosource 1.5. An EBP sign and PPE (gown, gloves, goggles) were present at the room, and staff acknowledged the resident was on EBP. However, during incontinence care and tube feeding administration, the CNA and LPN only used hand hygiene and gloves and did not don gowns as required for high-contact care activities under EBP. Another resident with hemiplegia, type 2 diabetes, bladder dysfunction, hypertension, an indwelling urinary catheter, and ESBL colonization also had an order for EBP. During dressing, transfer with a sit-to-stand lift, and handling of the urinary catheter collection bag, two CNAs wore gloves but did not wear gowns, despite signage and available PPE and their acknowledgment that gowns should be used for EBP care. Additionally, the facility did not complete the TB risk assessment on an annual basis as required by its policy. Documentation showed a TB risk assessment was completed on one date in 2026, but there was no documentation that a TB risk assessment had been completed in 2025. The Infection Preventionist confirmed the absence of documentation for a 2025 TB risk assessment, despite the facility’s policy stating that a TB risk assessment shall be conducted annually to determine appropriate administrative, environmental, and respiratory protection controls based on the current TB risk classification.
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