Infection Prevention and Control Failures in Water Management, TB Screening, and Wound Care
Summary
The facility failed to develop and implement complete infection prevention and control policies and procedures for its water systems. The Water Program Review dated 06/19/25 did not contain additional details, and the facility-specific program did not include control measures or control limits for identified hazardous conditions at control points such as ice machines, the main kitchen, the satellite kitchen, sinks, tubs, showers, and toilets. During the facility tour, multiple spas, an unused satellite kitchen, and multiple resident showers were observed. A bathroom sink in one resident room was observed with brown water, and a housekeeper stated water was run in resident rooms daily for about 30 seconds and that brown water had been seen in sinks that were not used regularly. The maintenance director stated housekeeping ran water in every room monthly for two minutes, but this was not documented, and the administrator stated the program should include facility-specific control measures and corrective actions for identified potentially hazardous conditions. The facility also failed to ensure employee TB screening was completed according to policy for five of ten employee files reviewed. The employee TB screening policy required a two-step Mantoux test unless there was documentation of a prior positive reaction, with the second test given within 14 days after the original test if the first was negative. Dietary D’s file lacked documentation of the second PPD, CMT E’s file lacked documentation of any PPD test, Housekeeper F’s first and second PPDs were administered after the hire date, Social Services’ file lacked a read date for the first PPD and lacked documentation of the second PPD, and CNA G’s file lacked documentation of the second PPD. The DON stated new employees should receive the two-step PPD prior to working on the floor with residents and should receive annual screening, and the administrator gave the same expectation. The facility further failed to ensure resident TB screening was completed and documented for three of six sampled residents. The resident TB screening policy directed that residents be screened upon admission and at intervals appropriate for the region, with a two-step PPD upon admission unless testing had been done by the transferring hospital within 30 days prior to admission. Resident #2, Resident #14, and Resident #18 each had admission records reviewed that did not contain documentation of a first or second step TB test. The DON stated a two-step TB should be completed on admission and annual screening should be done, and the administrator stated TB records were not being kept up to date and would be uploaded if completed. The facility also failed to provide wound care in a manner that reduced the risk of infection for two residents. Resident #6 was cognitively intact, at risk for pressure injuries, and had one unhealed stage II pressure injury; the physician order directed skin prep to the right heel twice daily. During wound care, RN A wore gown and gloves, left the room with PPE on, removed gloves at the treatment cart, replaced gloves without hand hygiene, handled gauze, returned to the room, and cleaned the resident’s bloody right toe without performing hand hygiene between tasks. Resident #30 was cognitively intact and had heart failure and diabetes mellitus; orders directed daily wound care for bilateral lower leg blisters. During observed care, RN A placed clean supplies on the bed between the resident’s legs, placed soiled bandages and scissors on the clean barrier, used the same soiled gloves while moving between wounds, left the room with PPE on, removed gloves in the hallway, replaced gloves without hand hygiene, used tongue suppressors to apply cream, and placed soiled scissors in the treatment cart drawer without cleaning or disinfecting them. The DON, administrator, and RN A all stated that hand hygiene, glove changes, clean barriers, and separating wound care tasks were expected during wound care.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with an indwelling Foley catheter had EBP identified in the care plan, but staff did not consistently wear gowns during close contact care, including vital signs, medication administration, hygiene-related contact, and topical treatment. In addition, a TMA administered medications to three residents without sanitizing hands between residents or before handling medications, despite policy and DON expectations requiring hand hygiene. Laundry practices were also inconsistent with sanitary handling, as staff sorted soiled laundry without gowns and gloves being available in the room and reported using only gloves for most dirty laundry tasks.
An LVN failed to follow hand hygiene and insulin pen preparation practices during a medication pass for a resident with diabetes. After washing his hands, he turned off the faucet with his bare hand, then administered insulin without cleaning the insulin pen’s rubber seal with alcohol first. The DON stated both actions were a break in infection control, and the facility policy required proper hand hygiene and noted that gloves do not replace hand hygiene.
Failure to perform hand hygiene during wound care was identified for a resident with a stage 4 coccyx pressure ulcer, diabetes, CAD, and HTN. An RN and the ADON provided perineal and wound care, but the RN repeatedly changed gloves without sanitizing hands and did not sanitize hands or change gloves before removing soiled packing and applying new wound packing and a dressing. The DON stated staff were expected to sanitize hands every time gloves were removed, and facility policy required hand hygiene after glove removal and before moving from a contaminated body site to a clean body site.
An RN failed to follow hand hygiene and safe medication handling during med pass, including touching dropped tablets and handling meds without gloves or hand hygiene between steps. The facility also failed to store nebulizer mouthpieces and masks in labeled bags when not in use for residents receiving respiratory treatments, including a resident with CHF, CKD, DM2, and anemia. The DON confirmed the expected storage and handling practices were not followed.
An LPN was observed cleaning a community-use glucometer with an alcohol pad instead of the bleach wipe or equivalent required by the facility policy. The LPN stated he always used alcohol pads, while the DNS stated staff were to use bleach wipes. The glucometer was used for CBG checks on several residents with diabetes, and their records did not indicate a BBP.
A resident with MRSA and an abdominal wound was observed during wound care with contracted wound care staff entering without proper PPE, touching room items, and performing wound care without consistent hand hygiene or glove changes while moving from dirty to clean tasks; the same staff then went to another resident’s room without gowns despite EBP signage. The facility also failed to timely replace another resident’s oxygen tubing for CPAP/oxygen use, and the tubing had no label showing when it was last changed.
Failure to Use EBP, Perform Hand Hygiene, and Maintain Sanitary Laundry Practices
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling Foley catheter. The resident’s annual MDS identified cognitive impairment, diagnoses including obstructive and reflux uropathy, bladder neck obstruction, and urine retention, and that the resident used an indwelling catheter. The care plan, revised 6/8/26, directed staff to follow infection control protocols, post an EBP sign on the resident’s door, communicate the need for EBP, and use appropriate PPE during high-contact care. During observation, the resident had an EBP identifier and sign posted, and PPE supplies were available outside the room, but staff did not consistently wear gowns during close contact care. An LPN entered the resident’s room wearing gloves but no gown to obtain vital signs, stood close while applying and removing the blood pressure cuff, then removed gloves, performed hand hygiene, retrieved medications, and returned to the room without gloves or a gown to administer medications while touching the overbed table, water mug, and personal belongings. A NA entered the room without a gown or gloves and stood against the bed with her uniform touching the linens and overbed table before exiting after using hand sanitizer. An RN applied topical cream to the resident’s legs while wearing gloves but no gown. The nurse manager stated all staff were expected to wear a gown and gloves whenever coming into close contact with the resident, while the RN stated gowns were only needed when emptying the catheter. The facility also failed to ensure hand hygiene during medication administration for three residents. A TMA prepared and administered medications to three residents without washing or sanitizing hands between residents or before handling medications, and stated she only sanitized her hands when medications were powdery or when giving lactulose. The DON stated staff were expected to sanitize hands before and after preparing medications for a resident and between residents, and the medication administration policy required hand hygiene before passing medications, prior to handling medications, and after coming in contact with a resident. In addition, laundry services were not conducted in a sanitary manner: the soiled laundry room contained multiple soiled laundry bins, no gowns or gloves were available in the room, and a laundry worker stated she wore only gloves except when removing items from the soaking bin or handling biohazard bagged laundry. The housekeeping/laundry supervisor stated staff were expected to wear a gown and gloves whenever working with dirty laundry and remove them before working with clean laundry.
Infection Control Lapses During Insulin Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when an LVN failed to follow hand hygiene and insulin administration practices during a medication pass for a resident with diabetes. Resident #97 was cognitively intact, had diagnoses including diabetes, peripheral vascular disease, acquired absence of left toes, and acquired absence of the right leg below the knee, and was ordered Lantus insulin 30 units subcutaneously twice daily. During observation, the LVN washed his hands in the resident’s bathroom and turned off the faucet with his bare hand instead of using a paper towel, then returned to the medication cart and administered insulin without cleaning the rubber seal of the insulin pen with alcohol first. During interview, the LVN stated that after washing hands the faucet should be turned off with a paper towel because the handle could be contaminated and germs could be reintroduced, and he acknowledged he did not realize he had turned it off with his bare hand. He also stated he was not sure the rubber seal on the new insulin pen had to be cleaned with alcohol before use, despite having skills training within the year. The DON stated the nurse should have wiped the rubber seal with alcohol before inserting the needle and should have used a paper towel to turn off the faucet because it was cross contamination and a break in infection control. The facility’s hand hygiene policy stated all staff must perform proper hand hygiene procedures and that gloves do not replace hand hygiene.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure infection prevention practices, including hand hygiene, were followed during wound care for a resident with a stage 4 coccyx pressure ulcer. The resident was cognitively intact and had diagnoses including diabetes mellitus, coronary artery disease, and hypertension. The resident’s assessment and care plan identified chronic pressure ulcers, diabetic foot ulcers, dependence for several activities of daily living, and a history of being noncompliant with repositioning and often refusing to get out of bed. During observation of wound care, the clinical manager RN and the ADON entered the resident’s room wearing gowns and gloves and began perineal care and wound care. The RN removed and replaced gloves multiple times while cleansing stool from the resident’s buttocks and upper thigh, but did not sanitize her hands after removing soiled gloves. The RN then gathered wound care supplies, removed the wound packing, measured the wound, and packed the pressure ulcer with new packing and applied a dressing without sanitizing hands or changing gloves before beginning the new wound packing and dressing application. During interview, the RN confirmed she had not sanitized her hands after each glove change and had not sanitized her hands or changed gloves after removing the soiled packing before applying the new wound packing and dressing. The DON stated her expectation was that staff sanitize hands every time gloves are removed and that after a wound is cleansed, staff should remove gloves, wash hands, and apply new gloves before applying new dressings. The facility policy stated hand hygiene should be performed after removing gloves, after handling clean or soiled dressings, and before moving from a contaminated body site to a clean body site during resident care.
Infection Control Failures During Medication Pass and Respiratory Equipment Storage
Penalty
Summary
The facility failed to follow infection control standards for hand hygiene during medication administration for 2 of 5 observed medication passes. During one observation, an RN poured a tablet into her hand from a blister pack and administered it to a resident. During a second observation, the RN performed hand hygiene, used a tissue as a barrier, and poured medications for another resident, but when a Hydroxychloroquine tablet fell onto the medication cart she picked it up and discarded it without performing hand hygiene before continuing. An Eliquis tablet fell onto the tissue barrier and was handled without gloves, and a Divalproex tablet was also poured into the RN’s hand before being placed into the medication cup. The RN then entered the resident’s room and administered the medications. The facility also failed to follow infection control standards for storage of respiratory equipment for 3 of 7 residents reviewed for respiratory services. During an observation, an RN removed a nebulizer T-mouthpiece from a gray plastic basin on a nightstand; the mouthpiece was not stored in a bag. The RN administered an Albuterol nebulizer treatment to the resident. The RN stated the mouthpiece is normally stored in a bag when not in use and that she should have gotten a new one and discarded the one not bagged before giving the treatment. The DON stated the nebulizer mouthpiece and mask should be stored in a bag when not in use and that staff should have disposed of the mouthpiece and gotten a new one. Record review and observations showed Resident #2, who had diagnoses including hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, type 2 diabetes, and anemia, had a nebulizer mask sitting next to the machine on the bedside table and left open to air rather than secured in a labeled bag. The same condition was observed again in the resident’s empty room two days later. The DON stated the expectation was that nebulizer equipment be stored in a bag labeled for the resident when not in use, and if it was not stored appropriately it should have been removed and replaced with new equipment. Resident #2 had an order for Ipratropium-Albuterol nebulizer solution, and the MAR showed it was administered multiple times in July.
Improper Cleaning of Community-Use Glucometer
Penalty
Summary
The facility failed to ensure a community-use glucometer was cleaned with an EPA-approved disinfectant for 1 of 4 halls reviewed for infection control, specifically Hall 2. The facility’s 10/2025 glucometer cleaning policy stated staff were to clean glucometers with a bleach germicidal wipe or equivalent, but on 7/7/26 at 7:46 AM an LPN was observed cleaning a community-used glucometer with an alcohol pad and stated he always used alcohol pads to clean the glucometers. The LPN identified residents on Hall 2 who had CBG checks as Residents 7, 13, 63, 68, 71, and 99. Each of these residents had diabetes, and their clinical records did not indicate they had a BBP. At 8:38 AM, the DNS stated staff were to use bleach wipes to clean the community-use glucometers.
Failure to Use PPE During Wound Care and Replace Oxygen Tubing Timely
Penalty
Summary
The facility failed to ensure that all staff, including contracted wound care staff, wore appropriate PPE and performed hand hygiene during wound care for a resident with intact cognition, peripheral vascular disease, an abdominal wall ulceration, and MRSA. A contact precautions sign was posted on the resident’s door requiring hand hygiene, gloves, gown, and dedicated or disposable equipment. During observation, the facility LPN washed hands and donned gown and gloves, but contracted wound care staff entered the room without appropriate PPE, touched the resident’s bedding and items in the room, and later proceeded with wound care after being asked to put on gowns. During the wound care, the contracted staff performed care on the resident’s abdominal wound without changing gloves or performing hand hygiene when moving from dirty to clean tasks. One staff member released the abdominal fold, removed the old dressing, measured the wound, and applied a new dressing while another staff member reached into the wound cart with an ungloved, unwashed hand, opened a sterile package, and handed it to the physician. The physician then leaned over the resident’s bedding and obtained a wound sample. After leaving the room, the staff removed PPE and performed hand hygiene, then went to another resident’s room for wound care without placing gowns on despite the enhanced barrier precautions sign posted there. The facility also failed to change oxygen tubing timely for a resident with COPD, sleep apnea, oxygen therapy, and CPAP use. The resident stated the oxygen tubing had not been changed since admission and that the tubing in use had been provided by the resident because staff used it instead of obtaining one from supply. The tubing was observed without any label showing when it had last been changed, and staff could not confirm the last change because there was no order documenting weekly tubing changes. Facility staff stated oxygen tubing was expected to be changed weekly, but the resident’s orders did not include a weekly tubing change order.
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