Inadequate Infection Control Program and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program, as evidenced by improper cleaning and maintenance of resident-care equipment and lack of annual review of infection control policies. During an observation, a common bathtub in the North hallway was found with long streaks of dark, rust-colored stains and dried brown sediment around the drain. The bathtub lacked signage or a cover to indicate it was out of use. A staff member reported that the bathtub had not been cleaned in five or six months and confirmed it was not being used by residents, with only the toilet and sink in use in that bathroom. The staff member also believed that housekeeping audits were being conducted monthly by another staff member. Review of facility policies revealed that the cleaning and disinfection policy for resident-care equipment was last updated in April 2025, and both the Water Management Program Policy and Legionella Surveillance Policy had not been reviewed or revised since April 2020. The facility assessment indicated that routine maintenance and cleaning schedules existed for most equipment, with non-routine maintenance conducted as needed. However, when documentation was requested for cleaning or deep cleaning of the North hallway tub and for housekeeping audits from June 2024 to the present, no records were provided by the end of the survey.