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:
Failure to Follow EBP and Hand Hygiene During Incontinence Care: A resident with a catheter, hospice care, heart failure, and a lumbar compression fracture had a care plan for EBP requiring gown and gloves for high-contact care. During incontinence care, a CNA provided care without a gown, touched the bed linens, curtain, and gown with a uniform, and handled stool-soiled items without changing gloves or performing hand hygiene. A second CNA assisted with turning and wiping stool but changed gloves without hand hygiene; an RN later stated the PPE and hand hygiene used were not appropriate.
Infection Control and EBP Not Used During Wound Care Three residents with open wounds received wound care from RNs without PPE, and there was no PPE or precaution signage outside their rooms. The nurses and leadership stated the residents were not on EBP because the wounds were not infected or were considered simple dressings, even though the facility policy required gown and glove use for wound care involving any skin opening requiring a dressing and identified complex/infected wounds as EBP indications.
Failure to follow EBP during urinary catheter care: an LPN provided catheter care to a resident without wearing the required PPE gown, despite an EBP sign posted on the room door and gowns being available at the entrance. The nurse stated he wore a gown for contact precautions but not for EBP and was unaware a gown was required for catheter care; the IP, DON, and Administrator all stated a gown was expected for this high-contact activity.
A resident admitted for skilled nursing services did not have documented TB testing completed on admission. A T-spot was later drawn, but there was no record that the specimen was sent to the lab or that results were obtained. The DON stated the facility missed the resident during TB audit checks and that the sample was not processed because the lab form was not sent with it, despite the facility policy requiring TB screening and testing within 72 hours of admission.
The facility failed to maintain infection control for two residents. An RN did not sanitize hands between glove changes while administering medication via a resident’s PEG tube, despite the resident being on EBP and having a care plan for tube feeding and meds via PEG. In another instance, a resident with respiratory failure had oxygen tubing left unbagged when not in use, even though staff stated it should be bagged to prevent contamination.
A resident with klebsiella, a UTI, MDR organism status, an indwelling urinary catheter, and IV access was on contact precautions with signage at the door requiring hand hygiene, gown, and gloves before entry. A CNA entered the room and answered the call light without PPE, and later stated she only used PPE for catheter care. The charge nurse and DON stated staff were expected to wear PPE whenever entering the contact isolation room.
Failure to Follow EBP and Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to follow infection control practices related to enhanced barrier precautions and hand hygiene for Resident 12. Resident 12 was readmitted with diagnoses including heart failure, end of life care (hospice), and a compression fracture in the lumbar area, and was able to communicate needs. The care plan, initiated on 01/19/2026, directed staff to use enhanced barrier precautions because of the resident’s catheter, including wearing a gown and gloves for high-contact care. During observation on 06/17/2026, Staff H, a CNA, answered Resident 12’s call light and provided incontinence care without wearing an isolation gown, using only gloves. While providing care, Staff H touched the bed linen, privacy curtain, and the resident’s gown with a uniform. Staff H then removed the front part of the incontinent brief and wiped loose stools with wipes, while touching the privacy curtain, bed linens, and a pillow on the chair next to the bed with soiled gloves without changing gloves or performing hand hygiene. A second CNA entered with gown and gloves and assisted with turning the resident and wiping loose stools from the back, but changed gloves and did not perform hand hygiene. Staff J, RN, later entered the room and applied ointment, and stated Staff H should not have provided care without proper PPE and hand hygiene. The DON stated staff were to perform hand hygiene before putting on gloves when changing gloves and after using gloves, and that staff not following EBP and lack of hand hygiene did not meet expectations.
Infection Control and Enhanced Barrier Precautions Not Used During Wound Care
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of disease for three residents and two nurses reviewed for infection control. During wound care observations, RN B entered a resident’s room to provide care for a stage 3 pressure ulcer on the right glute without PPE, and there was no visible PPE outside the room or signage indicating transmission-based precautions. RN A also entered two other residents’ rooms without PPE while providing wound care, and there was no visible PPE outside those rooms or signage indicating transmission-based precautions. Resident #3 was a male with diagnoses including Alzheimer’s disease, prostate cancer, depression, hypertension, and peripheral vascular disease. His MDS showed severe cognitive impairment and one stage 3 pressure ulcer. His care plan and physician orders directed wound care to the right glute. During observation, RN B provided wound care without PPE. In interview, RN B stated the resident was not on enhanced barrier precautions because the wound was not infected, and she stated enhanced barrier precautions were only needed for complex wounds requiring multilayer dressings. She also stated she had been trained in enhanced barrier precautions. Resident #66 was a female with diagnoses including left femur fracture, muscle weakness, and hypertension. Her MDS showed moderate cognitive impairment and one unstageable deep tissue injury. Her care plan and physician orders directed daily wound care to the left heel. During observation, RN A provided wound care without PPE. Resident #85 was a male with diagnoses including Alzheimer’s disease, edema, diabetes, and hypertension. His MDS showed moderate cognitive impairment and risk for pressure ulcers. His care plan and physician orders directed daily wound care to bilateral lower leg wounds. During observation, RN A provided wound care without PPE. RN A stated both residents were not on enhanced barrier precautions because the wounds were not infections, and she stated she had been trained in enhanced barrier precautions. The DON, ADON, IP, and ADM all stated that the three residents were not on enhanced barrier precautions because their wounds were not infected or were simple dressings. The DON and ADON stated enhanced barrier precautions were used for residents with complex wound dressings, infections, or certain devices such as Foley catheters, PICC/CVL lines, drains, or wound vacs. The facility policy stated enhanced barrier precautions are used to reduce the spread of MDROs, are indicated for complex/infected wounds, and require signs outside the room and PPE available near or outside the room. The facility sign also stated staff must wear gloves and gown for wound care involving any skin opening requiring a dressing.
Failure to Follow EBP During Urinary Catheter Care
Penalty
Summary
The facility failed to follow its infection control policy and procedure for Enhanced Barrier Precautions (EBP) when Nurse #1 did not don a protective gown before providing urinary catheter care to Resident #7. The facility’s Infection Prevention and Control Program stated that EBP was designed to reduce transmission of multidrug resistant organisms by requiring gown use during high-contact resident care activities, including urinary catheter care. A sign posted on the resident’s room door instructed staff to wear a gown for urinary catheter care, and a PPE storage container with gowns was available at the room entrance. During observation, Nurse #1 entered the room, washed his hands, put on gloves, and performed catheter care, including cleaning the catheter insertion site and tubing and flushing 30 milliliters of acetic acid into the catheter tubing, without wearing a gown. After removing his gloves, he cleaned his hands with sanitizing wipes. In interview, Nurse #1 stated he did not wear a PPE gown for a resident on EBP and was not aware that a gown should be worn during urinary catheter care. The Infection Preventionist stated EBP signs were used as reminders and instructions for required PPE, and that Nurse #1 had recently attended an in-service on EBP. The DON and Administrator both stated they expected Nurse #1 to follow EBP and wear a gown during catheter care.
Incomplete TB Testing on Admission
Penalty
Summary
The facility failed to ensure that 1 of 5 sampled residents, R12, had completed TB testing upon admission. R12’s admission record showed admission to the facility in March 2026 for skilled nursing services. A progress note dated 5/11/26 documented that an interferon-gamma release assay (T-spot) test was drawn, but there was no further documentation showing that the specimen was sent to the laboratory or that results were obtained. There was also no documentation showing that TB testing had been completed at admission in March 2026 rather than as a delayed test in May 2026. During interview, the DON stated the facility had been auditing for missing TB testing and had missed R12 during that process; she explained that blood had been drawn for the T-spot, but the facility forgot to send the form with the sample to the lab, so the process ended there. Review of the facility’s Resident Tuberculosis Prevention and Control policy showed that all new resident admissions were to have TB screening and testing completed within 72 hours of admission.
Infection Control Lapses With PEG Medication Administration and Oxygen Tubing Storage
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 32 residents reviewed for infection control. One deficiency involved a resident with a PEG tube, severe cognitive impairment, stroke, colon cancer, diabetes, hyperlipidemia, hypertension, and kidney disease. During medication administration through the PEG tube, RN E did not sanitize her hands between glove changes while giving acetaminophen via the tube. RN E stated she was supposed to sanitize her hands between glove changes when giving medications through a PEG tube, and the DON stated hand sanitizing between glove changes was important to prevent cross contamination during PEG medication administration. The resident’s record showed an active order for acetaminophen via PEG tube and a care plan noting the resident required tube feeding, meds, and water flushes only. The care plan also noted the resident was on enhanced barrier precautions. The facility policy stated hand hygiene is the primary means of preventing transmission of infection and includes hand hygiene after removing gloves. RN E’s hand hygiene checkoff documented training on hand washing with soap and water and hand sanitizer. A second deficiency involved a resident with acute and chronic respiratory failure with hypoxia who used oxygen at night. Observation showed the resident sitting in his room with an oxygen concentrator near his bed and oxygen tubing unbagged and secured around the top. The resident stated his tubing was not bagged and staff had not provided a bag for when it was not in use. RN C stated the tubing should be bagged when not in use to prevent dust or dirt particles from entering and causing infection, and the DON and ADM stated unprotected oxygen tubing could lead to cross contamination. The facility respiratory policy stated the oxygen set-up should be dated and stored in a treatment bag when not in use.
Failure to Use PPE in Contact Isolation Room
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for Resident #31, who was admitted after hospitalization with diagnoses including klebsiella pneumoniae and a UTI, and who was also documented as having a multi-drug-resistant organism, an indwelling urinary catheter, and intravenous access. The resident’s hospital record showed he had been diagnosed with a multi-drug-resistant organism UTI and treated with IV antibiotics through a PICC line under isolation contact precautions. The admission report form documented that the hospital RN reported the resident needed contact isolation precautions and IV antibiotic meropenem. Resident #31’s physician ordered contact precautions due to bacteremia klebsiella, and the care plan identified infection, antibiotics for urosepsis, multidrug-resistant organism, and risk for adverse reactions, with universal standard precautions to prevent cross contamination and spread of infection. During observation, the resident’s room had contact precaution signage stating that staff must clean hands before entering and when leaving, put on gloves and gown before room entry, and discard them before room exit. Despite this signage, CNA E answered the resident’s call light and entered the room without putting on any PPE. During interview, Resident #31 stated staff sometimes wore gowns and gloves but had not done so when the CNA came in to reposition him. CNA E stated she entered the room without PPE and said she would wear PPE only when providing urinary catheter care, not when she was not providing catheter care. The charge nurse stated CNA E had been trained to wear PPE whenever entering the room and that the resident was cared for under contact isolation precautions. The DON stated the expectation was for all staff entering a contact isolation room to perform hand hygiene and don a gown and gloves before entry and remove PPE before exiting.
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