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F0880
D

Deficient Infection Control Practices in Housekeeping and Catheter Care

Colorado Springs, Colorado Survey Completed on 07-24-2025

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

The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene and cleaning protocols by housekeeping staff and improper infection control procedures during urinary catheter care. Housekeeping staff were observed cleaning resident rooms without performing hand hygiene between glove changes or between cleaning different rooms. The housekeeper did not allow the disinfectant solution to remain on surfaces for the full manufacturer-recommended dwell time before wiping, and failed to disinfect high-touch surfaces such as call lights, television remotes, door knobs, and light switches. These actions were not in accordance with both CDC guidelines and the facility's own policies, which require proper hand hygiene and thorough cleaning of high-touch surfaces to prevent the spread of infection. During urinary catheter care for a resident with a suprapubic catheter, the infection preventionist did not perform hand hygiene after assisting the resident to bed and after touching potentially contaminated surfaces, such as the bathroom faucet. The infection preventionist also failed to perform hand hygiene before donning new gloves at multiple points during the procedure, including after removing soiled gloves and before continuing with catheter site care. These actions were inconsistent with CDC recommendations and the facility's policies, which specify that hand hygiene must be performed before and after glove use, and particularly before invasive procedures such as catheter care. Interviews with facility staff, including the maintenance director, assistant director of nursing, and regional director of clinical operations, confirmed that the observed practices did not align with established protocols. Staff acknowledged that hand hygiene should be performed after glove removal and before resident care, and that disinfectant solutions require a specific dwell time to be effective. The failure to follow these procedures was directly observed and documented during the survey, leading to the identified deficiencies in the facility's infection prevention and control program.

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