Deficient Infection Control Practices and Water Management
Penalty
Summary
The facility failed to maintain an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in its plumbing system. Observations during facility tours revealed multiple unused water lines protruding from pantry and activity room walls, as well as discolored water dispensed from hopper faucets and sprays in soiled utility rooms. Some hopper spray foot pedals were turned off at the source, indicating stagnant water lines. Interviews with environmental services staff confirmed that only annual Legionella samples were taken, with no testing for free chlorine or other disinfection levels, and that hot water boilers were set below the recommended temperature for pathogen control. Facility documentation stated that irregularly used or low-flow fixtures should be flushed at least twice per week, but staff reported only flushing fixtures in certain areas, with no evidence of a comprehensive flushing protocol for all minimal-use outlets. The facility also failed to implement proper infection prevention practices and appropriate use of personal protective equipment (PPE) for two residents. One resident, who was non-ambulatory, dependent on staff for ADLs, and receiving hospice care, was observed with a stained urinal placed directly on the overbed table next to open food and drink, without a barrier. This practice was repeated over multiple observations, and staff interviews revealed that there was no care plan or documentation indicating the resident had requested the urinal be kept on the overbed table. Facility policy required urinals to be stored in a cabinet or drawer, not on the overbed table, especially near food. Additionally, staff were observed not following proper PPE and hand hygiene protocols during medication administration. An LPN was seen wearing gloves used for insulin administration out of a resident's room and handling items on the medication cart before removing gloves and performing hand hygiene. Another nurse was observed touching the rims of medication cups with bare, unwashed hands while separating them. Interviews with nursing leadership confirmed these actions were not in accordance with facility policy, which required removal of gloves and hand hygiene before leaving resident rooms and avoiding contact with the rims of medication cups.