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F0880
E

Infection Control Lapses in Linen Handling and Enhanced Barrier Precautions

San Diego, California Survey Completed on 05-07-2025

Penalty

No penalty information released
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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

Surveyors observed multiple infection control deficiencies within the facility. Clean linens were found stored in direct contact with packages transported from an outside laundry service, with the Director of Environmental Services (DES) and Infection Preventionist Nurse (IP) confirming that packaging should be removed before linens are placed in closets. Additionally, trash cans, including one containing used gloves, were present inside clean linen closets, which both the DES and IP acknowledged should not occur. The clean linen closets also had visible dust and debris on the floor, contrary to facility policy and staff statements that these areas should be kept clean and free from trash and dust. A licensed nurse was observed administering medications to a resident with a gastrostomy tube (GT) who was under Enhanced Barrier Precautions (EBP) without wearing the required isolation gown. The nurse performed hand hygiene and wore a face mask but did not don a gown, later stating she was unaware of the requirement. EBP signage posted outside the resident's room clearly indicated that gown and gloves were required for high-contact activities such as device care, including feeding tubes. The Director of Nursing (DON) confirmed that all staff are expected to adhere to infection control procedures.

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