F0880

J

Failure of Infection Control Program Leading to C. diff Outbreak, Legionella Risk, and Environmental Contamination

Napa, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and maintain an effective infection prevention and control program, resulting in a C. difficile (C. diff) outbreak and multiple lapses in basic infection control practices. Eight residents were confirmed positive for C. diff between 11/12/25 and 1/24/26, and three residents had active C. diff infections on the survey entrance date. The Infection Preventionist (IP) could not describe the facility’s surveillance program for communicable diseases and was unable to provide a tracking log for such infections. The facility’s Infection Prevention Policy and Procedure Manual lacked a specific policy or protocol for C. diff and did not cite national standards for infection control, despite referencing regulatory requirements that call for written standards, policies, and procedures, including when and how isolation should be used and what hand hygiene procedures staff must follow.

Staff interviews and observations showed widespread confusion and inconsistency regarding appropriate disinfectants and equipment use for C. diff. Multiple unlicensed staff and housekeeping personnel reported or were observed using products not effective against C. diff, such as Clorox disinfectant spray and Medline MicroKill One alcohol-based wipes with violet or lavender tops, instead of bleach-based products labeled as killing C. diff spores. Some staff stated that residents on C. diff precautions should have dedicated vital signs equipment, but in practice, shared vital sign towers and reusable stethoscopes were routinely brought into isolation rooms and then wiped down, often with non-bleach products. In several C. diff isolation rooms, no dedicated blood pressure cuffs or vital sign equipment were present, and staff acknowledged that there were only a few vital sign towers in the facility, preventing them from being left in isolation rooms as dedicated equipment.

Hand hygiene and isolation practices were also deficient. Staff were observed exiting resident rooms, including those on contact precautions, without performing hand hygiene, and some staff admitted forgetting to wash their hands or not knowing that soap and water for 20 seconds were required for contact precautions. A nurse was observed attempting to wash hands at a nurses’ station sink that did not have warm water or paper towels, and a nurse practitioner stated she did not wash hands in a contact precaution room’s bathroom because she considered it contaminated, without being able to state the facility’s hand hygiene policy. Staff were observed providing direct care to residents on contact precautions without gowns, and bedside care staff could not consistently verbalize appropriate PPE use or the correct disinfectant for shared equipment in C. diff rooms.

Resident placement and bathroom use for C. diff-positive residents were not managed according to the facility’s own written expectations for individualized room placement and dedicated equipment. Two residents with C. diff shared a bathroom with residents who did not have C. diff, and the DON and IP could not describe a clear process for ensuring the bathroom was cleaned with bleach after each use or how staff would monitor and document such cleaning, especially when residents used the bathroom independently. The DON stated she was not concerned about a C. diff resident sharing a bathroom with non-C. diff residents and acknowledged there was no process to ensure cleaning after each use. When discussing the use of bedside commodes for C. diff residents, both the DON and IP were unable to explain how staff would empty the commodes if the shared bathroom was not to be used, and there was no clear plan for preventing cross-contamination in these scenarios.

Medical record reviews showed delays and inconsistencies in initiating isolation precautions for residents with suspected or confirmed C. diff. For one resident, a positive C. diff result was obtained on 11/6/25, but the resident was not moved to an isolation room until 11/10/25. Another resident had loose stools documented on CNA task sheets, with a stool specimen collected and later confirmed positive for C. diff, and contact precautions were not initiated until days after the specimen was sent and the positive result obtained. For another resident, documentation indicated multiple episodes of loose, foul-smelling stools and a positive C. diff result, with contact precautions initiated only after the result was received, despite CDC guidance that patients with three or more stools in 24 hours should be isolated immediately when C. diff is suspected. These delays occurred in the context of a documented outbreak, with 11 C. diff cases identified over a one-year period on the facility’s surveillance log.

The facility also failed to implement an effective water management program for Legionella as part of its infection control system. The water system was tested in February 2025, and 9 of 10 samples were positive for Legionella, with documentation describing excessively high levels of Legionella, low to zero chlorine residuals, very high occupant susceptibility, and an immediate risk to patient health. The testing company strongly recommended immediate implementation of a water management program and noted that such a program is mandated by CMS. However, the IP could not fully describe the facility’s Legionella prevention program or monitoring activities, did not know the test results, and confirmed that Legionella monitoring and prevention were not discussed in Infection Control Committee (ICC) meetings. The Administrator and Regional Corporate Director acknowledged that the water system had not been retested for Legionella between February 2025 and early 2026, and QAPI minutes showed that although a performance improvement plan was initiated in March 2025 to monitor weekly hot water flushing and implement a water management program, there was no further documented follow-up, discussion, or recommendations through the end of 2025.

In addition, environmental infection control in a communal shower room was deficient. During an observation of the northwest resident shower room, the IP noted that the room appeared dim and that a large diameter pipe near the floor, in an area where a toilet might have been, was stuffed with wet paper towels. The IP stated it was an infection risk to have wet paper towels in that location. The shower room was also used to store medical equipment, compounding the concern about contamination from an open sewage pipe area that had been plugged with wet paper products. This condition existed in a shared space used for resident hygiene and equipment storage, further demonstrating the facility’s failure to maintain a sanitary environment as part of its infection prevention and control program.

Removal Plan

• Update the C. Diff policy and procedure to include bathroom use and the frequency of cleaning and disinfecting equipment, rooms, and bathrooms.
• Train the Infection Preventionist on the infection surveillance program for monitoring and tracking and on the facility's Infection Control and Prevention Program.
• Provide in-services to all Licensed Nurses and Certified Nursing Assistants on the C. diff policy and procedure, including appropriate use of personal protective equipment.
• Ensure every isolation room has dedicated vital signs equipment and cleaning solution.
• Review all residents' medical records to determine whether they have had any change of condition that would indicate C. diff infection.
• Have the Medical Director provide solutions and measures to prevent the spread of infections.