Infection Control Deficiencies: PPE Use and Linen Handling
Summary
Staff failed to adhere to infection prevention and control practices for a resident placed on contact precautions due to scabies. During an observation, a CNA was seen inside the resident's room feeding the resident without wearing an isolation gown, despite a contact precautions sign posted outside the room instructing staff to don PPE before entry. The CNA stated that there was no isolation gown available at the designated supply area and acknowledged that a gown should have been worn. After donning a gown and completing care, the CNA discarded the used gown in a regular trash bin, which was overflowing with used gowns, instead of the designated biohazard bin. The CNA explained that the appropriate bin was not available in the room at the time. Further interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the CNA did not follow proper gowning and disposal procedures. The IP stated that gowns must be donned before entering isolation rooms and disposed of in the correct bin. The Environmental Services Director also acknowledged the lack of a designated trash bin for used PPE in the room and stated that designated bins had been provided and checked the previous day. Additionally, improper handling of clean linens was observed. A CNA was seen placing clean linen on top of a dirty hamper outside the resident's room. Both the CNA and the Environmental Services Director confirmed that this was not in accordance with facility policy, which requires clean linens to be handled and stored in a manner that prevents contamination. The IP verified that the clean linens were now considered contaminated due to this action.
Plan Of Correction
F880 Infection Prevention & Control A. How the facility plans to correct the specific deficiencies cited: * Failure to ensure staff donned an isolation gown and properly discarded it: Immediate in-service education was provided to CNA 4 on June 17, 2025, regarding proper donning, doffing, and disposal of isolation gowns, emphasizing the importance of donning prior to entering an isolation room and proper disposal in designated biohazard bins. All nursing staff and environmental services staff will receive mandatory re-education on June 25th regarding the facility's Infection Prevention and Control policies and procedures, specifically focusing on: * Correct application and removal of all types of Personal Protective Equipment (PPE), particularly isolation gowns, when providing care to residents on transmission-based precautions. * Proper disposal of contaminated PPE into designated biohazard waste receptacles immediately after removal. * The importance of ensuring designated biohazard bins are readily available and not overflowing in isolation rooms. Environmental Services will implement a daily checklist for all isolation rooms to ensure adequate stock of PPE (including isolation gowns) at the designated supply area outside the room and the availability of empty biohazard waste bins within the room starting June 25th, 2025. This checklist will be reviewed by the Environmental Services Director or designee. * Failure to handle clean linens to prevent the spread of infection: Immediate re-education was provided to CNA 5 on June 18, 2025, regarding the proper handling and storage of clean linens, emphasizing that clean linens must never be placed on dirty hampers or other contaminated surfaces. All nursing staff and environmental services staff will receive mandatory re-education on June 25th, 2025 on the facility's policy for Handling Clean Linen, reinforcing the importance of: * Maintaining separation between clean and dirty linens at all times. * Transporting and storing clean linens in clean, designated containers or carts. * Never placing clean linens on or near contaminated surfaces, including dirty hampers. Nursing staff will be re-educated on the proper procedure for bringing clean linens into resident rooms to ensure they remain free from contamination. B. How other residents having the potential to be affected by the same deficient practice will be identified and what corrective action(s) will be taken: * All residents requiring transmission-based precautions will be identified through daily review of the facility's infection control log and resident care plans by the Infection Preventionist (IP) and Director of Nursing (DON). * An audit will be conducted for all residents currently on transmission-based precautions to ensure proper PPE is available outside their rooms and that appropriate waste receptacles are provided within their rooms. Any discrepancies will be immediately corrected. * The IP and DON will conduct focused observations during routine rounds to ensure all staff are consistently adhering to proper PPE utilization and disposal for all residents on transmission-based precautions. All nursing staff and environmental services staff will be re-educated on June 25th, 2025 on proper linen handling procedures to prevent contamination, ensuring all residents receive care with uncontaminated linens. C. What measures will be put into place or systemic changes made to ensure that the deficient practice does not recur: * Enhanced Staff Education and Competency: Comprehensive in-service training on Infection Prevention and Control, including proper PPE use, disposal, and clean linen handling, will be conducted for all nursing staff (RNs, LVNs, CNAs) and environmental services staff by July 15, 2025. This training will include practical demonstrations and return demonstrations to ensure competency. New employee orientation will include a dedicated and enhanced module on infection prevention and control practices. Annual competency evaluations will include observation of proper PPE use and linen handling for all staff involved in resident care. * Increased Environmental Monitoring during Angel Rounds: The existing Angel Rounds checklist will be revised to include specific checks for all resident rooms, especially those with residents on isolation precautions: * Verification of PPE availability: During Angel Rounds, nursing supervisors/designees will visually confirm that appropriate PPE (e.g., isolation gowns, gloves) is stocked and readily accessible at the designated supply area outside isolation rooms. * Trash Bin Monitoring: During Angel Rounds, nursing supervisors/designees will visually inspect all trash bins within resident rooms and bathrooms to ensure they are not overflowing with used PPE or other waste and that designated biohazard bins are present and utilized for waste disposal. The QAPI Committee will review all infection control incidents, audit results, and staff competency records on a monthly basis for a period of six months, and quarterly thereafter. Specific data points to be monitored will include: * Number of observed instances of non-compliance with PPE use and disposal. * Number of observed instances of improper clean linen handling. * Completion rates of staff education and competency evaluations related to infection control. * Findings from Angel Rounds related to PPE and trash bin monitoring. The QAPI Committee will track trends related to infection control practices and identify areas requiring further intervention, such as additional staff training, revised procedures, or environmental modifications. Corrective actions will be implemented as needed based on QAPI findings, and their effectiveness will be continuously evaluated by the QAPI Committee. The Administrator, DON, and IP will be responsible for overseeing the implementation of this Plan of Correction and ensuring ongoing compliance.
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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