F0880

F

Systemic Infection Control Failures Including Delayed EBP, Poor PPE Use, and Unsanitary Practices

Sault Ste. Marie, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures in the facility’s infection prevention and control program, including delayed implementation of Enhanced Barrier Precautions (EBP), improper use of personal protective equipment (PPE), lack of annual policy review, unsanitary medication and treatment carts, inadequate hand hygiene during feeding, and improper separation of clean and soiled meal trays. Surveyors observed a medication cart on B Hall with an open coffee and an energy drink on top, and the RN interviewed acknowledged that open drinks should not be on the cart. A treatment cart on D Hall was observed with dark rings resembling coffee stains and visible dust and debris under glove boxes, and another treatment cart on B Hall had disposable cups and straws on top with food crumbs and debris in and around the glove rack; an RN stated CNAs used the cart as an extra surface when passing meals, even though it housed wound care supplies.

The facility failed to timely initiate EBP for several residents who met criteria under the facility’s own EBP policy. Residents with surgical wounds, pressure ulcers, dialysis catheters, and indwelling urinary catheters had EBP orders initiated days to weeks after admission or after the condition was present. One resident admitted with a right tibia/fibula fracture and a surgical incision to the right leg had no EBP signage or PPE cart outside the room, and the EBP order was not entered until three days after admission. Another resident with a left tibia/fibula fracture, diabetes, chronic kidney disease, and a dialysis port had no EBP signage or PPE cart outside the room, and the EBP order was also delayed until 12 days after admission. Additional residents with a stage 2 pressure ulcer present on admission, a neck surgical incision, acute kidney failure with an indwelling catheter, and a right femur fracture requiring surgery all had EBP orders initiated between 3 and 14 days after admission or after the qualifying condition was documented.

Surveyors also observed staff not properly donning PPE when providing care to residents under EBP. An occupational therapist provided physical therapy to a resident with a surgical incision without wearing a gown, and an LPN removed a leg brace from another EBP resident without a gown, later stating he did not realize the resident was on EBP. In another instance, a CNA was seen pushing PPE carts into two residents’ rooms while a unit manager placed EBP signs on their doors, indicating EBP implementation was occurring well after the presence of surgical wounds and ongoing dressing changes documented in the medical record.

Hand hygiene and food service practices were also deficient. During a lunch meal, a CNA assisted three different residents with feeding, moving between them, handling different utensils, cups, plates, trays, and clothing protectors without performing hand hygiene at any time; when questioned, the CNA was unsure if hand hygiene was required between residents. During meal service on two different halls, food carts were observed containing both unserved meal trays and soiled trays together, with some soiled trays placed above or directly next to unserved trays, blocking service. CNAs who opened the carts acknowledged that dirty trays were not supposed to be placed with new trays. The facility’s hand hygiene policy required all staff to perform proper hand hygiene to prevent the spread of infection, and the FDA Food Code cited in the report requires food to be protected from cross contamination by proper arrangement and separation.

The facility’s infection prevention and control program policies, including the Infection Prevention and Control Program Policy and Procedures, Antibiotic Stewardship Program Policy, Influenza Vaccine Policy, and Pneumococcal Vaccine Policy, were reviewed/revised in late 2023, and the Infection Prevention and Control Program policy required an annual review of the program and associated policies. The infection preventionist acknowledged that delayed EBP implementation often occurred when she was out of the facility because there was no designated backup to oversee the process, and confirmed that the provided infection prevention and control policies were the most up-to-date versions available. These findings collectively demonstrate failures to implement and operationalize the infection prevention and control program as written, including timely EBP initiation, consistent PPE use, maintenance of sanitary carts, adherence to hand hygiene, and proper separation of clean and soiled food trays.