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F0880
E

Failure to Implement Infection Control Practices During Resident Care and Linen Handling

Mountain View, California Survey Completed on 07-14-2025

Penalty

Fine: $12,735
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Certified nursing assistants (CNAs) failed to follow established infection control practices in several instances. One CNA carried soiled linens out of a resident's room with gloved hands, dropped a piece of linen on the hallway floor, picked it up, and continued to the linen hamper outside the room. The CNA acknowledged that gloves should have been removed in the resident's room and soiled linens should have been placed in a plastic bag before disposal. In another instance, a soiled pillowcase was observed on the floor behind the door in a resident room that had recently been prepared for new occupants. The registered nurse confirmed that the soiled pillowcase should not have been left on the floor. Additionally, a CNA provided incontinent care to a resident on Enhanced Barrier Precautions (EBP) without wearing a gown, despite signage indicating that both gloves and a gown were required for such care. The CNA admitted awareness of the EBP sign and the need for appropriate personal protective equipment. The infection preventionist confirmed that staff should remove gloves in the resident room, prevent soiled linens from touching the floor, and wear gowns and gloves when providing care to residents on EBP.

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