Infection Control Deficiencies: Unlabeled Toothbrushes and Improper Catheter Care
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices affecting three out of five sampled residents. During observations, two toothbrushes were found in a shared bathroom without labels identifying which resident each belonged to. Unlicensed staff confirmed that the facility's policy requires toothbrushes to be labeled with resident names, especially when stored in shared spaces, to prevent confusion and accidental use by the wrong resident. The Director of Staff Development also verified that labeling is necessary for infection control and to ensure each resident uses their own toothbrush. Additionally, a resident with a Foley catheter was observed with the catheter tubing touching a fall mattress, which is considered a contaminated surface. Licensed nursing staff and unlicensed staff both acknowledged that facility policy prohibits catheter tubing from touching the floor or fall mattress due to the risk of contamination. The Director of Staff Development confirmed that such contact is unsanitary and could result in infection. A review of the facility's policies and procedures corroborated the requirements for labeling personal hygiene items and ensuring catheter tubing does not come into contact with contaminated surfaces. These lapses in following established infection control protocols were directly observed and verified by staff interviews, indicating a failure to maintain a safe and sanitary environment as required by federal regulations.
Plan Of Correction
F 880 F 880 F 880 F 880 SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to ensure residents are treated with respect and dignity, including the right to retain and use personal possessions, and to ensure call lights are answered promptly and catheter drainage bags are properly covered to maintain resident privacy and dignity. Corrective Action for Affected Residents: On 6/3/25, Resident 1's foley catheter drainage bag was immediately provided with a privacy cover. On 6/3/25, the Director of Nursing (DON) and DSD conducted one-on-one counseling with staff members who failed to respond to Resident 1's call light. The DON met with both Resident 1 and Resident 2 to address their concerns regarding call light response times and implemented immediate monitoring of call light response times for their rooms. Identifying other Residents having the Potential to be Affected: On 6/4/25, the DON and DSD conducted a facility-wide audit of all residents with foley catheters to ensure proper privacy covers were in place. A facility-wide assessment of call light response times was conducted for all residents from 6/4/25 to 6/6/25 to identify any additional concerns with call light response times. Measures put into place or Systemic Changes: The DON or designee will conduct in-service education for staff by 7/1/2025 on: • Call light response protocols and expectations for maximum response (promptly) • Proper use and importance of foley catheter privacy covers • Resident dignity and respect requirements • Staff accountability for responding to call lights regardless of assignment New processes implemented include: • Call light monitoring audit to track response times Plan to Monitor Performance: The DSD will conduct audits of call light response times and catheter privacy cover compliance weekly for 8 weeks, and monthly thereafter. Audits will include: • Random observations of call light response times • Review of call light monitoring audit data • Inspection of all catheter drainage bags for proper privacy covers & positioning • Interviews with residents regarding satisfaction with call light response times via audit tool The DON will analyze audit results and report findings to the Quality Assurance and Performance Improvement (QAPI) committee quarterly. The QAPI committee will review the effectiveness of interventions and make additional recommendations as needed until substantial compliance is achieved and maintained.