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F0880
D

Infection Control Deficiencies: Pathogen Tracking, Ice Storage, and Barrier Precautions

Waverly, Tennessee Survey Completed on 06-18-2025

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 adhere to its infection prevention and control program in several key areas. The Infection Preventionist/Assistant Director of Nursing did not track pathogens in the Monthly Infection Surveillance Report, as required by facility policy, and the surveillance form lacked a column to document the specific organisms being tracked. This was confirmed during an interview, and no documentation was provided to show that infection organisms were being monitored. Additionally, staff failed to maintain proper ice storage practices; an observation revealed that an ice scoop was left partially submerged in melted ice inside the ice storage container in one of the nourishment rooms, contrary to facility policy which requires the scoop to be kept in a covered container when not in use. Both a CNA and the DON confirmed that this was not in compliance with established procedures. Furthermore, the facility did not implement enhanced barrier precautions as required for a resident with a wound. The resident, who had diagnoses including Parkinson's Disease, protein-calorie malnutrition, and muscle weakness, had a care plan and physician's order specifying the need for enhanced barrier precautions during high-contact care activities. However, during an observed wound care procedure, the Wound Care Nurse performed hand hygiene and donned gloves but failed to wear an isolation gown before direct resident contact, despite confirming that an isolation gown should have been used for this resident under enhanced barrier precautions.

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