Failure to Replace Water Filters and Report Legionella Results
Summary
The facility failed to follow the manufacturer's recommendations for replacing Nephros water filters after a presumptive positive case of Legionella in a resident. Nephros filters, which are certified for 90 days of use, were installed on all faucets and shower heads but were not replaced as required. Observations revealed that several resident rooms and utility areas lacked the required filters, and interviews with the Maintenance Director and Administrator confirmed that filters were only replaced when they broke or fell off, not according to the recommended schedule. The Maintenance Director was unaware of missing filters, and there was no record-keeping of filter replacements. Additionally, the facility did not ensure timely notification to the state Department of Public Health when positive Legionella water sample results were identified, as required by their water management plan. Multiple water samples from various locations in the facility tested positive for Legionella, with results ranging from 1.2 to 31.9 CFU/ml. Despite these findings, documentation failed to show that the state agency was notified when results exceeded the threshold for reporting. The water management committee met regularly but did not document in detail how positive Legionella results were addressed. Interviews with key staff, including the Infection Preventionist and Medical Director, revealed gaps in communication and monitoring. The Infection Preventionist did not review water sample results or maintain a line list for Legionella monitoring, and residents in rooms with positive water samples were not specifically monitored. The Medical Director was unaware of the positive Legionella results and indicated that he would have ordered additional testing if informed. These failures resulted in a finding of Immediate Jeopardy, as the facility did not implement required infection prevention and control measures following the identification of Legionella.
Removal Plan
- Replace the water filters on all shower heads and previous resident care areas that tested positive.
- Ship 35 water filters overnight and replace.
- WC #2 adjusted chlorine levels per WC #1's guidance (from 1.0mg to 2.2mg).
- Order and install 115 additional water filters to be delivered and installed.
- Replace all water filters in the kitchen.
- Provide bottled water for drinking and oral care until the water filters are replaced/changed.
- Provide staff education on the use of bottled water for drinking and providing oral care.
- Continue to perform bi-weekly water sampling testing to be conducted by WC #1.
- Provide hand sanitizer for hand hygiene and disposable wipes for use in resident rooms.
- Mark sinks for non-use until water filters are replaced.
- Notify residents and families of the concern with the water.
- Continue to monitor residents and obtain physician orders to conduct further testing if indicated.
- Bag faucets and post signs identifying not to use in rooms without new water filters.
- Place wipes and hand sanitizers in every room.
- Place signs to not use the water on the front door and on the units.
- Educate every resident regarding the wipes and hand sanitizer in the affected rooms.
- Allow staff to use the shower room, staff bathroom, and soiled utility room sinks for hand washing.
- Deliver water bottles to all units.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
Surveyors found that residents were served meals in the dining room without being offered required hand hygiene before eating, despite facility policy mandating handwashing or alcohol-based hand rub use before handling food. A CNA and the DON both acknowledged that residents’ hands should have been sanitized prior to meals. Additional observations showed a housekeeper transporting clean gowns uncovered in a hallway and significant visible buildup of white and grey fuzzy substances on pipes, wires, equipment, and chemical buckets in the laundry area, with the housekeeper stating there was no formal cleaning schedule in place.
A resident receiving wound and catheter care was assisted by an RN and a CNA who donned gowns, N95 masks, and gloves before entering the room. After perineal and catheter care, the RN did not change gloves or perform hand hygiene and continued to separate the resident’s labia, adjust clothing, handle the bed pad, reposition the resident, and operate the bed controls with the same soiled gloves. This practice conflicted with the facility’s infection control policy, which requires removal of soiled gloves and handwashing when moving from dirty to clean tasks and after contact with potentially infectious material.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility did not follow its Legionella water management policy by failing to complete and document required monthly water temperature testing and flushing over a three‑month period. Review of water temperature monitoring logs showed no evidence of the mandated testing, and the interim Maintenance Director confirmed that no documentation existed for those months. This represented a failure to implement the facility’s infection prevention and control program as written.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inadequate Hand Hygiene and Environmental Cleaning in Infection Control Program
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to hand hygiene and maintaining a clean, sanitary environment. The facility’s Handwashing/Hand Hygiene Policy, revised March 2022, required use of alcohol-based hand rub or soap and water before and after eating or handling food. During a meal service observed at 12:04 PM on 4/12/26, 14 residents were served meals in the dining room without being offered hand hygiene before eating. At 12:12 PM, a CNA acknowledged that residents’ hands should have been sanitized before they started eating, and on 4/13/26 at 2:44 PM, the DON confirmed that residents in the dining room should have been offered hand hygiene using hand sanitizer from a bottle before meals. Additional infection control concerns were observed regarding environmental cleanliness and handling of clean items. On 4/14/26 at 6:53 AM, a housekeeper was seen carrying clean gowns down the hallway uncovered, and at 6:56 AM the housekeeper stated the gowns should have been covered. Later that morning at 8:36 AM, with the housekeeper present, surveyors observed multiple areas of visible buildup and residue in the laundry room, including a white hard substance and grey fuzzy substance on pipes behind a small washing machine, a tube of wires covered with grey fuzzy substance near the entrance, teal-colored and grey fuzzy substances on water pipes behind a large washing machine, a layer of white substance on the chemical dispenser cover, and grey fuzzy buildup on chemical buckets and nearby walls. At 8:41 AM, the housekeeper reported there was no cleaning schedule for the laundry room, although sweeping was done daily.
Failure to Perform Hand Hygiene and Change Gloves Between Perineal and Other Care Tasks
Penalty
Summary
Surveyors identified a failure to follow the facility’s infection control policy for hand hygiene and glove use during care for Resident 6. On 04/15/26 at 10:21 AM, the resident was observed resting in bed when a licensed nurse and a CNA donned gowns, N95 masks, and gloves before entering the room to assess a wound on the resident’s buttocks and provide catheter care. The resident was uncovered and noted to have no incontinent brief on. The CNA separated the resident’s buttocks and identified an open area approximately 0.3 cm long by 0.2 cm wide, then performed catheter care by cleansing the tubing from the insertion site down with a wet soapy washcloth followed by a dry washcloth. After this care, the licensed nurse assisted in repositioning the resident and, without changing gloves or performing hand hygiene, separated the resident’s labia, then used the same soiled gloves to pull down the resident’s front blouse, place hands on the cloth bed pad to help pull the resident up in bed, pull the sheet and blanket over the resident, place the bed control in the resident’s hand, and adjust the head of the bed. The nurse then removed and discarded the gloves, gown, and mask in a trash can. The nurse confirmed she had not changed gloves after assessing the resident’s labia and acknowledged she should have. The facility’s Infection Control Policy, revised 01/19/26, directed staff to remove soiled gloves, wash hands, and change gloves after contact with infectious material and before leaving the resident’s environment, and to wash hands immediately with antimicrobial soap. An administrative nurse stated she would expect staff to change gloves and wash hands when providing care, especially when moving from dirty to clean tasks.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Follow Legionella Water Management and Monitoring Policy
Penalty
Summary
The facility failed to implement its infection prevention and control measures related to Legionella control for three consecutive months. The facility’s written "Legionella Policy and Water Management Plan" dated 1/5/26 required monthly water temperature testing and flushing to ensure water was being maintained and to guide specific actions for prevention of Legionella and investigation should a case occur. Review of the water temperature monitoring logs for February, March, and April 2026 showed no evidence that the required monthly testing was completed during those months. During an interview on 4/10/26, the interim Maintenance Director confirmed that the facility had no documentation of water testing in accordance with the Legionella policy for February, March, and April 2026. This lack of documented monitoring and testing meant the facility did not follow its established system for surveillance and control of potential Legionella in the water system as outlined in its infection prevention and control program and related policies.
Plan Of Correction
The Facility has developed a Water Management Team which includes the Administrator, DON and Maintenance Director. Which has implemented control measures for Legionella testing within the facility following the "Legionella Policy and Water Management Plan" Both water temperature and water flushing logs were completed for the month of March and documented by the Maintenance Director. Water testing temperature logs and Water Flushing logs will be completed by the Maintenance Director as per the Legionella policy and Water Management Plan monthly. The Administrator has educated the Maintenance Director on the Legionella Policy and Water Management Plan. The Water Management Team have completed the Training from the CDC PreventLD. The Administrator will complete audits for completion of Legionella testing to include both the water temperature logs, and the water flushing logs monthly times four then quarterly times two. Results of this audit will be presented to the QAPI committee for review and further recommendations.
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