F0880

F

Inadequate Environmental Cleaning and Hand Hygiene in Infection Control Practices

Lakewood, Colorado Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program on two of three units, specifically in housekeeping practices and hand hygiene during resident care. Professional references cited in the report emphasize the importance of cleaning and disinfecting high-touch surfaces, following proper cleaning sequences from cleaner to dirtier areas, and adhering to disinfectant contact (dwell) times to prevent healthcare-associated infections. Facility policies on cleaning and disinfecting resident rooms and on hand hygiene require regular cleaning of environmental surfaces, appropriate selection and use of disinfectants, changing soiled cleaning materials, and performing hand hygiene at key moments, including before and after resident contact and after glove removal.

During observations of housekeeping practices, a housekeeper was seen cleaning a double-occupancy room using a single Clorox hydrogen peroxide disinfectant wipe on surfaces for both sides of the room, contrary to hygienic practice and without allowing the surfaces to remain wet for the manufacturer-required one-minute dwell time. The housekeeper sprayed the toilet with Spic and Span disinfectant and then used a toilet brush and a red rag to wipe the toilet rim, seat, and lid in a sequence that did not proceed from the cleanest to the dirtiest areas. Without changing gloves or performing hand hygiene after cleaning the toilet, the housekeeper then reached into the mop bucket twice to wet mop pads, thereby contaminating the cleaning solution, and proceeded to mop the bathroom and resident room. The housekeeper did not clean high-touch areas such as call lights, light switches, bed controls, or the resident sink area, and did not perform hand hygiene between rooms before donning new gloves.

In a triple-occupancy room, the same housekeeper again used Spic and Span to spray the toilet and collected trash, then used two Clorox hydrogen peroxide wipes to clean bedside tables and nightstands for two beds, leaving one bed’s nightstand and bedside table uncleaned and not maintaining the required dwell time, as the surfaces dried in about 30 seconds. The housekeeper used Spic and Span and a single rag to clean the sink area and mirror, wiping the mirror first and then the sink handles, bowl, and countertop, again not following a clean-to-dirty sequence. After scrubbing the toilet bowl with a toilet brush, the housekeeper touched the bathroom light switch, items on the cleaning cart, and then placed toilet paper in the bathroom while still wearing soiled gloves used for toilet cleaning. Although gloves were later changed, hand hygiene was not performed between glove changes.

The report also documents a failure to perform appropriate hand hygiene during wound and catheter-related care by the facility’s infection preventionist (IP). While providing suprapubic catheter care to a resident, the IP performed initial hand hygiene, donned PPE, removed the resident’s adult disposable brief, removed the old drain sponge, and cleansed and dried the suprapubic area using multiple clean washcloths before placing a new drain sponge and reattaching the brief. After removing PPE and washing her hands, the IP donned gloves and handled the resident’s garbage bag, used PPE, and an old Foley catheter bag to take them to the garbage disposal area. The IP did not change gloves and perform hand hygiene immediately after removing the soiled drain sponge, and the old Foley catheter bag, which was contaminated with bodily fluids, was not placed into a red biohazard bag. In interviews, the IP acknowledged that gloves should be changed after removing a dirty dressing, and the DON confirmed that the correct procedure would include removing the old dressing, removing gloves, washing hands, donning clean gloves, and discarding a dirty Foley catheter bag in a red biohazard bag.