Failure of Infection Control Program Leading to C. diff Outbreak, Legionella Risk, and Environmental Contamination
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident being evaluated for C. difficile was not consistently managed under the correct contact-enteric precautions. Staff gave care with incomplete understanding of the precautions, the room signage did not clearly identify the needed disinfectant or contact time, bleach wipes were not always available, and staff were observed missing hand hygiene and handling items under PPE during care.
Failure to Use EBP PPE During Wound Care: A resident with a wound and severely impaired cognition was receiving ordered wound care when the DON and ADON entered the room, washed hands, and donned gloves but did not wear gowns before starting care. EBP signage and PPE were present at the bedside, and both leaders later stated they forgot to put on gowns even though the resident was on EBP for an open wound and the facility policy required gown and glove use for wound care.
Staff failed to consistently follow EBP and hand hygiene for two residents who required high-contact care. One resident with an indwelling catheter and cognitive impairment did not have EBP followed during transfers, clothing removal, and pericare, and another resident with a suprapubic catheter and multiple pressure ulcers had staff wear PPE incorrectly, remove PPE in the room without hand hygiene, and continue care after emptying the catheter bag without changing gloves or cleaning hands. Interviews confirmed staff were expected to use gowns, gloves, and hand hygiene for these tasks.
A resident on Contact Precautions for active C. difficile infection was not consistently protected by required PPE. Although signage outside the room directed all entrants to wear a gown and gloves, an RN entered the room with medications without either item and touched the bedside table and door surface. The resident stated staff did not always wear gowns, and the DON confirmed staff were expected to wear a gown and gloves when entering the room while precautions were in place.
A facility failed to maintain infection control during care for two residents. During incontinence care, a CNA removed gloves and applied clean gloves without hand hygiene before placing a clean brief on a resident who was dependent for toileting hygiene and always incontinent. During ostomy care, an LVN handled a resident’s colostomy, wiped stool from the stoma, and continued care without removing soiled gloves, sanitizing hands, or putting on clean gloves. The DON stated staff were expected to perform hand hygiene between glove changes.
Infection Control Failures During Incontinent Care: Two residents were observed receiving incontinent care with multiple infection control lapses. A CNA did not perform hand hygiene between glove changes or after glove removal while caring for one resident, and another CNA did not wash hands before care, changed nothing between dirty and clean tasks, touched clean items with dirty gloves, placed soiled linens on the floor, and handled dirty linens with bare hands after glove removal. The DON stated hand hygiene, glove changes, and proper handling of soiled linens were required, and facility policies reflected those practices.
Infection Control Practices Not Consistently Implemented for Resident Evaluated for C. difficile
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident who was being evaluated for C. difficile. Resident #43 was admitted with diagnoses including anoxic brain damage, neuromuscular dysfunction of the bladder, and disorder of the autonomic nervous system. A laboratory test for C. difficile had been ordered, but the specimen had not yet been collected because the resident had not produced stool. During observation, a dental hygienist provided care to the resident while wearing a gown and gloves, and a Contact Precautions sign was posted outside the room. The hygienist stated no one had informed him/her that the resident was suspected of having C. difficile, and no one had instructed him/her about using bleach for disinfection or washing hands with soap and water. The infection preventionist stated the sign should have identified the precautions as contact enteric and that the resident should have been placed on the appropriate precautions when the order to obtain the specimen was initiated. Later observation showed a Contact Precautions Special Enteric sign, bleach wipes, gowns, and gloves outside the room, but the sign did not identify the disinfectant required for equipment or environmental disinfection. Bleach wipes were not available outside the room at one point, and staff interviews showed inconsistent knowledge of the precautions. One CNA stated he/she had never heard of contact enteric, another believed enteric precautions required a gown, goggles, and gloves, and another entered the room without performing hand hygiene before donning PPE. During care, one CNA removed gloves and handled a hand-held radio under the gown without hand hygiene, and another used alcohol-based hand sanitizer during glove changes while caring for the resident being evaluated for C. difficile. A licensed nurse stated soap and water and bleach wipes should be used, but did not know the required contact time, and the precaution sign did not identify that contact time.
Failure to Use EBP PPE During Wound Care
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of disease for one resident with a wound. Resident #6 was a female admitted with diagnoses including Parkinsonism, muscle weakness, dementia, and hypertension. Her MDS assessment showed a BIMS score of 06, indicating severely impaired cognition, and her care plan identified a stage 2 pressure ulcer to the right lower calf with ordered wound treatments. During wound care observation, the DON and ADON entered the resident’s room, washed hands, and donned gloves, but did not put on gowns before starting the wound care. EBP signage and PPE were observed hanging at the head of the bed. In interviews, the DON and ADON stated they forgot to put on gowns and acknowledged that the resident was on EBP for an open wound. The facility policy stated that EBP requires targeted gown and glove use during high-contact resident care activities, including wound care, and that gowns and gloves are to be applied prior to performing the activity.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling catheter and for a resident with an indwelling suprapubic catheter and multiple pressure ulcers. One resident had moderate cognitive impairment, Type 2 diabetes, obstructive reflux uropathy, and required an indwelling catheter with staff assistance for toileting. His care plan directed staff to use EBP, including gowns and gloves for high-contact care such as toileting, hygiene, and wound care. During observation, a nurse donned a gown and gloves, but a nursing assistant did not don a gown or gloves while assisting the resident with transfers, clothing removal, pericare, and cleaning feces from the resident’s skin. The second resident was cognitively intact and had multiple sclerosis, obesity, diabetes mellitus, a right below-the-knee amputation, neurogenic bladder, obstructive uropathy, an indwelling suprapubic catheter, bowel incontinence, and dependence on staff for toileting, showering, dressing, hygiene, repositioning, and transfers. He also had a stage 4 pressure ulcer on the left buttock with a wound vacuum, a stage 3 sacral pressure ulcer, and a chronic diabetic left foot ulcer. His care plan required EBP for catheter care, dressing, bathing, transferring, changing linens, changing briefs, toileting, and wound care. During observations of care for this resident, staff did not consistently follow EBP or hand hygiene practices. One nursing assistant wore a gown open to the front while providing care, removed gown and gloves in the room without hand hygiene, and handled linens, trash, and the wastebasket before returning to the room. Another nursing assistant emptied the catheter bag and cleaned the catheter tip without changing gloves or performing hand hygiene, then continued with pericare and repositioning using the same gloves. Additional observations showed staff removing PPE in the room, leaving without hand hygiene, and handling the Hoyer lift and other items while wearing or after removing contaminated PPE. Staff interviews and the DON’s statements confirmed that staff were expected to follow EBP and change gloves and perform hand hygiene after high-contact tasks such as emptying a catheter bag, but the observed practices did not match those expectations.
Failure to Use Required PPE for Resident on Contact Precautions
Penalty
Summary
The facility failed to ensure required PPE was used for a resident on Contact Precautions for C. difficile infection. The resident’s MDS identified multiple diagnoses, including congestive heart failure, heart disease, kidney problems, and recurrent C. difficile, and the care plan required Contact Precautions and a private room due to the infection. Nursing documentation identified the resident had active C. difficile infection, and later notes indicated Contact Precautions were discontinued after the last full day of isolation. During observation, Contact Precautions signage outside the resident’s room directed all people entering to wear a gown and gloves, and PPE supplies were located across the hall. The resident stated staff did not always wear a gown when entering the room but usually wore gloves. An RN entered the room with medications without wearing a gown or gloves and touched the bedside table and the interior surface of the room door. The RN stated staff used the signage to determine PPE requirements and confirmed she did not wear a gown or gloves because she was only delivering medications. The interim DON confirmed staff were expected to wear a gown and gloves when entering the room while Contact Precautions were in place, and the facility policy required staff to put on a gown and gloves before contact with the resident or the resident’s environment.
Infection Control Lapses During Incontinence and Ostomy Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when CNA C did not perform hand hygiene before applying clean gloves during incontinence care for a resident with hemiplegia and hemiparesis following cerebral infarction, unspecified urinary incontinence, and bowel incontinence. The resident’s record showed she was dependent for toileting hygiene and always incontinent of urine and bowel. During observation, CNA C cleaned the resident’s buttocks, rolled the soiled draw sheet under the resident’s hip, removed gloves, did not perform hand hygiene, applied new gloves, and then applied a clean brief. When interviewed, CNA C stated she should have performed hand hygiene when changing gloves and said she was nervous. The DON stated staff were expected to perform hand hygiene between glove changes and that staff had received training on infection control and incontinent care. The facility also failed to ensure proper glove use during ostomy care for a resident with dementia and colostomy status. The resident’s orders included checking the skin around the stoma for redness and irritation, colostomy care every shift and as needed, and emptying the pouch every shift and as needed. During observation, LVN E removed the soiled dressing and emptied the pouch, observed brown substance on the stoma, wiped it off, and placed it in a garbage bag. LVN E then affixed the pouch and cleaned the dressing without removing the soiled gloves, sanitizing his hands, or applying new clean gloves. The DON stated the nurse policy and procedures followed from the named source had no mention of changing gloves between dirty and clean, and LVN E stated he was busy talking and did not remove the old gloves, though he said best practice was to change gloves between dirty and clean.
Infection Control Failures During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents during incontinent care observations. For one resident with Alzheimer’s disease, morbid obesity, muscle weakness, and dependence for toileting hygiene, CNA B provided most of the incontinent care while another CNA assisted with turning. During the care, CNA B changed gloves but did not wash or sanitize her hands before putting on new gloves, did not wash or sanitize her hands after removing gloves, and did not wash or sanitize her hands before transferring the resident with a mechanical lift. CNA B later stated she forgot to switch gloves at the end and did not sanitize her hands because she forgot to bring sanitizer with her. CNA A observed that CNA B did not wash or sanitize her hands between glove changes. For another resident with cerebral palsy, BPH, hypertension, severe cognitive impairment, and total incontinence of urine and bowel, CNA C performed incontinent care without washing or sanitizing her hands before starting and without changing gloves or washing her hands during and after care. While wearing the same gloves, she removed the resident’s shoes and pants, handled clean clothing from the closet, touched items in the room, handed the resident objects from the dresser, opened the resident’s refrigerator, and later handled dirty linens with bare hands after removing her gloves. She also placed dirty linens on the floor during the care. CNA C stated she had not been taught that she had to change gloves during incontinent care and was not sure when glove changes or hand hygiene should occur. The DON stated hand hygiene should be performed before care, before gloves were applied, after care was completed, and between residents, and that gloves should be changed when moving from dirty items to clean items. The DON also stated soiled linens should be placed in a plastic bag and not on the floor, and staff should never touch clean items with dirty gloves. Facility policies reviewed for perineal care, hand hygiene, and laundry and bedding soiled reflected these same practices.
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