Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by a lack of timely identification, reporting, and management of a COVID-19 outbreak. The Medical Director was not notified of the initial COVID-19 case until 7-10 days after it was identified, despite facility records showing the first resident and staff member tested positive 11 days prior. By the time of the survey, 16 residents and 8 staff members had tested positive. Additionally, although 8 residents had provided consent for the COVID vaccine, none received it before becoming infected, and vaccination only began 10 days after the initial case was identified, despite prior planning to receive the vaccine. Environmental observations revealed significant lapses in sanitation and cleanliness throughout the facility. Surveyors noted dirty floors, debris, dust-covered bathroom fans, unclean toilets, and evidence of mold and mildew in bathrooms. Common areas and resident rooms contained soiled furniture, food debris, and unsanitary conditions such as dirty shower chairs, broken tiles, and unbagged trash cans. High-touch surfaces were not regularly disinfected, and cleaning supplies and protocols were not consistently followed. Interviews with facility staff, including the Infection Preventionist and Administrator, confirmed that housekeeping was inadequately staffed, leading to irregular cleaning schedules. Leadership team members were assisting with cleaning duties, but there was no evidence of recent education, training, or audits related to cleaning practices. The lack of routine and targeted cleaning and disinfection of high-touch and common area surfaces was inconsistent with CDC guidelines and contributed to the facility's failure to control the spread of infection.