F0880

F

Failure to Maintain Comprehensive Infection Control Program and Adhere to EBP, PPE, and Linen Handling Standards

Farmington, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to maintain an ongoing, comprehensive infection prevention and control program. Review of infection surveillance data for several months showed that the facility did not compile ongoing data to identify appropriate antibiotic usage, track trends, clusters, or outbreaks, conduct ongoing surveillance, or provide staff education on infection control principles. For January, no ongoing data had been compiled at all. For December, November, and October, there were no monthly summaries documenting the prevalence of different types of infections or calculated infection rates, despite surveillance reports listing 27, 28, and 36 total infections respectively.

In the monthly surveillance reports reviewed, there were no documented signs and symptoms for any of the infections to demonstrate that they met appropriate criteria for antibiotic usage. In December, 17 infections were treated with antibiotics, 3 infections were left blank regarding whether they met criteria, and 7 were documented as meeting criteria despite no documented signs and symptoms. In November and October, the "Criteria Met" column documented infections as either True or False without any recorded signs and symptoms, and many entries had "No Response" for test results, test type, and infection type. The origin of infections was inconsistently and unclearly documented, with categories such as "Acquired Prior," "NA," and "Null" used without clear definitions, and the DON later stated infections should only be categorized as present on admission or developed in the facility. Mapping for trends, clusters, and outbreaks was incomplete and did not clearly correspond to all infections listed in the surveillance reports.

Interviews further demonstrated a lack of oversight and continuity in the infection control program. The DON reported that the facility had four different infection preventionists over the last year and acknowledged that the data should list signs and symptoms, accurately document whether infections were present on admission or facility-acquired, and include completed maps to demonstrate trends or outbreaks. The DON could not explain the terms "Prior" and "NA" used in the surveillance reports. The Administrator stated they were not aware of the status of the infection control program and reported that the last infection preventionist did not report to the QAPI committee. The facility’s own infection prevention and control policy required a program designed to prevent the development and transmission of communicable diseases and infections, but the documented practices did not align with this policy.

Surveyors also observed deficiencies in environmental infection control related to linen storage. In the basement storage area, two large metal carts containing linens and resident care equipment were not covered, and several shelves of linens were visibly soiled with debris particles. Inside a locked storage room, the floor was heavily soiled with dark stains, debris, and trash, and the ceiling showed visible water damage with broken, bubbling, and discolored areas. Ceiling particles were observed on the floor, on top of shelves, and on the emergency water supplies. Cardboard boxes containing blankets were stored directly under damaged ceiling pipes, and the boxes were compromised by water damage. These conditions conflicted with facility policies requiring clean linens to be handled, transported, and stored in a manner that prevents contamination by dust, debris, and other soiled items.

Additional observations showed noncompliance with hand hygiene and personal protective equipment (PPE) requirements under Enhanced Barrier Precautions (EBP). Rooms for multiple residents had EBP signage and PPE available, indicating the need for gowns and gloves. A respiratory therapist was observed providing tracheostomy tubing care and checking oxygen levels for a resident under EBP while wearing only gloves and then exiting the room without performing hand hygiene. The same therapist later provided respiratory care to another resident under EBP wearing only gloves and again did not perform hand hygiene after care. On another occasion, the respiratory therapy manager provided respiratory care to a resident under EBP while wearing only gloves. The respiratory therapy manager acknowledged that staff must wear proper PPE, including gowns, when providing care and touching residents. These practices were inconsistent with facility policies requiring appropriate PPE use and proper hand hygiene for all staff having contact with residents and their environment.