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F0880
E

Infection Control Failures in Laundry, Storage, and Respiratory Care

Sacramento, California Survey Completed on 05-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and staff interviews. In the clean linen area, dust particles were found on vents above the area and blackish particles had accumulated on the fan blades. The Housekeeping and Laundry Supervisor confirmed these findings and acknowledged that the fan was dirty and should have been cleaned. Additionally, the daily lint cleaning log was incomplete for a specific shift, despite laundry being processed during that time, and clean items such as pillows and mop heads were stored in the soiled linen area. The supervisor confirmed that all staff are responsible for keeping the laundry area clean and that vents are cleaned monthly or as needed. Further deficiencies were observed in the utility room, where soiled linen and trash containers were stored alongside medical supplies, oxygen concentrators, and personal hygiene items. One container was overflowing with the lid open, and a clear plastic bag containing soiled linen was present. Both the Infection Preventionist and the Director of Nursing confirmed that this storage practice posed a risk for cross contamination and agreed that clean items should not be stored in the dirty linen room. Facility policies reviewed indicated that storage areas should be kept clean and free from trash, and that soiled linen should be handled with standard precautions to prevent contamination of clean linen. For one resident with chronic obstructive pulmonary disease and obstructive sleep apnea, an opened and unlabeled container of distilled water was observed on the floor in the resident's room, which was being used nightly for CPAP therapy. The Infection Preventionist initially stated it was acceptable for the jug to be on the floor, but later clarified that it should not be placed there due to infection control concerns. Nursing staff confirmed that distilled water is used for CPAP and should not be kept on the floor, and that opened containers should be labeled. Facility policies required distilled water used in respiratory therapy to be dated and initialed when opened, and discarded per manufacturer guidelines, but these procedures were not followed.

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