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F0880
F

Deficient Infection Control in Laundry Handling and Legionella Water Management

Belen, New Mexico Survey Completed on 11-18-2025

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 follow proper infection control practices in two key areas: handling of laundry contaminated with used sharps and implementation of an adequate Water Management Program (WMP) to minimize the risk of Legionella. Observations revealed that laundry staff found used shaving razors in dirty towels brought to the laundry room, and these razors were subsequently placed in sharps disposal containers. The laundry technician reported finding razors in the laundry but could not recall when or to whom the incidents were reported. Both the Infection Control Preventionist and the Director of Nursing were unaware of these incidents, indicating a lack of communication and reporting regarding the presence of sharps in laundry. Facility policy on needle handling and sharps injury prevention did not address the risk of sharps contaminating linen or provide guidance on preventing such occurrences. Additionally, the facility's WMP was found to be inadequate in several areas. The policy lacked procedures for using control measures to prevent the introduction and spread of Legionella in the building's water system, did not specify control limits or parameters, and failed to include monitoring procedures or environmental testing protocols for Legionella. There were also no established interventions for when control limits were not met or in the event of a healthcare-associated legionellosis case. During interviews, facility leadership acknowledged that the WMP was reviewed annually but were unaware of its deficiencies in addressing Legionella risk.

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