F0880

E

Failure to Use Enhanced Barrier Precautions and Maintain Sanitary Resident Environment

Morton, Illinois Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), during indwelling urinary catheter care for one resident and to maintain a sanitary, homelike environment for two residents. The facility’s Infection Surveillance, Tracking and QA policy dated 12/2025 requires monitoring adherence to infection control practices, including proper use of PPE and ensuring proper precautions are initiated. The resident census roster shows multiple residents residing on the A Wing hallway. One resident (R7) had diagnoses including urogenital implants, benign prostatic hyperplasia with lower urinary tract symptom impairments, and urinary retention, and the care plan specified EBP related to an indwelling urinary catheter, including gown and glove use during high-contact care such as hygiene and device care. On 3/9/26 at 9:48 a.m., an LPN (V12) performed suprapubic catheter care for R7 without wearing a gown or mask, despite being assigned to the entire A Wing hallway and acknowledging not using this PPE. The Administrator (V1) later stated that nurses should always wear a gown, gloves, and mask when providing catheter care and that EBP is required.

The deficiency also includes failure to maintain a clean and safe environment in a resident room shared by two residents (R11 and R12). The Administrator job description requires ensuring the facility is maintained in a clean and safe manner, and the housekeeper job description requires following cleaning schedules, coordinating with nursing, cleaning resident living areas and floors, and discarding waste in proper containers. On 3/7/26 at 10:32 a.m., surveyors observed a soiled wet incontinence brief, a white bath towel with an approximately eight-inch area of brown matter, wet maroon sweatpants, a wet brown sweatshirt, and yellow non-skid socks on the floor in front of the commode in R11 and R12’s room. At 1:09 p.m. the same day, the same soiled items remained on the floor in front of the commode. On 3/8/26 at 8:15 a.m., a clear bag containing the soiled maroon sweatpants, brown sweatshirt, and yellow non-skid socks was observed on the floor in front of the sink in the same room. The Administrator stated that it was unacceptable for the soiled clothing, towel, and dirty incontinence brief to remain on the bathroom floor for that length of time.