F0880

E

Infection Control Failures in Wound Care, Housekeeping, and Catheter Management

Morrison, Colorado Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in the facility’s infection prevention and control program related to wound care, housekeeping practices, hand hygiene, and catheter management. During wound care for Resident #3, an LPN gathered supplies from the treatment cart and entered the resident’s room with the supplies tucked against her scrub top. The bedside table, which had visible white residue, was wiped only with a paper towel dampened with water and a single pump of hand soap, and no disinfectant or barrier pad was used before placing wound care supplies directly on the table. The LPN then left the room wearing the same gown and gloves to obtain assistance in the hallway and returned to complete the dressing change without changing all PPE, only changing gloves as needed.

During the wound procedure, the LPN and a CNA turned the resident, and the CNA noted the resident was wet and needed a brief change. The LPN removed an old dressing with moderate serosanguinous drainage, performed hand hygiene, and applied clean gloves. The LPN sprayed wound cleanser directly on the wound and placed gauze that had been sitting directly on the soiled bedside table under the wound to catch drainage. The LPN then cleaned the wound using the same piece of gauze ten times, did not place a barrier pad under the resident to protect the bed linens, and did not wear a mask while spraying the wound. In a subsequent interview, the LPN stated she believed wound care was a clean, not sterile, procedure and that antibacterial soap and water were sufficient to disinfect the table. She also reported she did not know she should not clean the wound with the same piece of gauze, did not know she needed a clean working area on the table or under the resident, and did not know she needed to wear a mask during wound care.

Housekeeping practices also failed to meet infection control standards. One housekeeper, while cleaning multiple resident rooms, repeatedly changed gloves without performing hand hygiene between glove changes. He used a pink solution labeled as Airlift Fresh and various colored rags to clean bedside tables, dressers, countertops, soap and towel dispensers, door knobs, wheelchairs, sinks, air conditioners, oxygen concentrators, blinds, and other surfaces, but did not use a disinfectant solution on these high-touch areas. In bathrooms, he used an acid bathroom cleaner and rags to clean toilets and risers but did not consistently clean from clean to dirty surfaces, and he splashed toilet water onto already cleaned surfaces by striking the toilet brush against the inner portion of the toilet riser. He also used the same mop bucket solution and mop pads in a sequence that contaminated the mop water with soiled gloves and did not use a separate clean mop pad for the bathroom versus the bedroom. In interviews, the housekeeper reported he had not received proper training, did not know the dwell time for disinfectants, did not know what cleaner was in the mop solution, believed hand hygiene was only needed when moving between rooms, and was unaware of how many rags to use in double-occupancy rooms.

The deficiency further includes improper management of urinary catheter tubing. For Resident #16, surveyors observed the resident in a wheelchair with catheter tubing lying on the floor, and on another occasion observed the same resident in bed with the catheter tubing again lying on the floor. A CNA stated that CNAs emptied the catheter every shift. An LPN confirmed that the catheter tubing was on the floor, repositioned it onto the bed so it was no longer touching the floor, and stated that the catheter should not have been on the floor because the floor was dirty and that catheter tubing on the floor increased the risk of infection. The infection preventionist stated that catheters should be kept off the ground and that there should be a barrier between the catheter and the floor. The facility’s catheter care policy did not specify that catheters should not be touching the ground, and the CDC guidance referenced in the report states that collection bags should be kept below the level of the bladder and not rest on the floor.