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F0880
D

Failure to Follow Infection Control Protocols During Equipment Cleaning

Grass Valley, California Survey Completed on 07-30-2025

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

Facility staff failed to follow infection control practices when two Certified Nurse Assistants (CNAs) disinfected a Hoyer lift in the hallway without wearing gloves and did not perform hand hygiene after cleaning the equipment. The CNAs used CaviWipes, a disinfectant that, according to its safety data sheet and facility policy, requires the use of gloves due to the risk of skin irritation and potential for infection transmission. After cleaning, the CNAs immediately entered a resident's room with the Hoyer lift without washing their hands or using hand sanitizer. Interviews with the CNAs confirmed that they were aware gloves should have been worn and hand hygiene performed after cleaning the equipment. The facility's infection preventionist also confirmed that the Hoyer lift should have been cleaned in the resident's room, not in the hallway, and that proper personal protective equipment and hand hygiene protocols were not followed during the observed incident. Facility policies reviewed indicated clear requirements for cleaning and disinfecting equipment, use of PPE, and hand hygiene, which were not adhered to in this instance.

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