Widespread Infection Control Failures in Facility
Penalty
Summary
Multiple infection prevention and control deficiencies were identified throughout the facility. In the medication rooms, supplies and medications were found stacked in corners and on the floor due to inadequate shelving, and countertops were cluttered and soiled, with personal items and debris present. The medication refrigerator contained spilled wine and food, and had not been cleaned, with staff confirming that nursing was responsible for its maintenance but had not done so. Overflowing sharps containers were also observed on the floor, and various rooms, including utility and shower rooms, had uncleanable surfaces, missing or broken flooring, and visible contamination such as feces, mildew, and trash left unremoved. Staff failed to follow proper infection control practices during resident care. One staff member donned gloves before a gown and touched her hair with gloved hands, then continued to gather supplies without changing gloves, contrary to facility policy. During wound and IV care for a resident, the same staff member repeatedly failed to perform adequate hand hygiene, washing hands for less than the required 20 seconds, touching contaminated surfaces, and handling supplies and wounds without proper glove changes or handwashing. The staff member also did not properly secure PPE gowns during care, only tying them near the end of the procedure, and admitted to not following protocol because the gown was inconvenient. Environmental cleaning and supply storage were also deficient. Showers were not cleaned between resident use due to lack of available cleaning supplies, and clean linens and briefs were stored on floors and in sinks. Staff interviews revealed a lack of accountability and communication regarding cleaning responsibilities and supply management. Resident council minutes and resident interviews reflected dissatisfaction with the cleanliness and odors in shower rooms, and concerns about wound healing. Facility policies on hand hygiene and cleaning were not followed, as evidenced by direct observation and staff statements.