Infection Control Failures and Unsanitary Conditions Identified
Penalty
Summary
The facility failed to maintain a sanitary environment and implement appropriate infection prevention and control practices across multiple areas. Surveyors observed storage closets and supply rooms containing a mix of clean linens, care products, and various forms of trash, including used medical gloves, open and uncapped ointments, personal items, and soiled incontinence briefs in disarray. Some items, such as incontinence briefs, were found touching visibly stained walls, and clean linens were stored on floors coated with black debris and cobwebs. Additionally, respiratory and medical supplies were stored directly on the floor or uncovered on shelves, and personal items were mixed with medical supplies, further compromising sanitation. Staff were observed failing to follow proper infection control protocols, including hand hygiene and the use of personal protective equipment (PPE). In one instance, a nurse donned PPE but handled a personal cell phone and case with gloved hands before entering a resident's room, only correcting the error after surveyor intervention. Another nurse entered a resident's room and handled the resident's bed covers without performing hand hygiene before or after the interaction. There was also a lack of appropriate signage to indicate necessary precautions for residents requiring special infection control measures, such as those with tracheostomies and tube feedings. The facility did not maintain up-to-date documentation confirming that all employees were free from communicable tuberculosis (TB). Two employees' files lacked current evidence of TB clearance, with one file missing any documentation and another containing only an outdated chest x-ray report. Additionally, the 2nd floor shower room was repeatedly found in unsanitary condition, with soiled linens, used personal care items, and open bottles of soap left in the room. Staff interviews confirmed that residents should have individual bathing items, but shared and improperly stored items were observed on multiple occasions.