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F0880
E

Infection Control Failures in Medication Administration and Environmental Cleaning

Berkeley, California Survey Completed on 05-22-2025

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

Staff failed to follow infection prevention and control practices during medication administration and environmental cleaning. Licensed Vocational Nurses (LVNs) were observed using blood pressure cuffs on multiple residents without cleaning the equipment between uses. The BP cuffs were placed on the medication cart, which was also not cleaned between residents. This practice was observed with six residents, and the Director of Nursing (DON) confirmed that the facility's policy required equipment to be cleaned between residents, which was not followed. Housekeeping staff also failed to adhere to infection control protocols. One housekeeper wore a protective gown used for laundry services outside the laundry room, including in resident areas such as the dining room and hallway. The DON stated that the gown was considered contaminated and should not have been worn outside the laundry area, as it could spread infection. Additionally, the housekeeper had not received in-service training on environmental cleaning since being hired and was unaware of the correct disinfectants to use for high-touch surfaces, instead using adult wipes not effective for disinfection. Further deficiencies were observed in the laundry area, where clean linens were stored in the dirty section of the laundry room near where soiled articles were rinsed. Some clean linens were covered with sheet protectors that touched the floor, leading to contamination. The DON acknowledged that these practices did not comply with facility policies, which require precautions to prevent cross-contamination and regular in-service training for housekeeping and laundry staff.

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