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F0880
D

Failure to Perform Hand Hygiene Between Incontinence Care and Handling Clean Brief

Prospect Heights, Illinois Survey Completed on 12-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to follow the facility’s hand hygiene policy during incontinence care for resident R11. On 12/9/25 at 11:31 AM, CNAs V15 and V16 repositioned R11 to her left side and it was observed that R11 was soiled with urine. V15 removed the soiled disposable adult brief and cleansed the perineal and sacral areas with disposable cleansing wipes. After completing the cleansing, V15 did not remove gloves and did not perform hand hygiene. Immediately after providing incontinence care, V15 handled a clean disposable adult brief and placed it underneath R11 without performing hand hygiene in between. This practice was inconsistent with the facility’s hand hygiene policy, revised 5/8/24, which requires staff to perform hand hygiene after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin, and after handling items potentially contaminated with blood, body fluids, or secretions. When informed of the observation, the ADON (V3) acknowledged that V15 should have performed hand hygiene after incontinence care and before handling the clean brief.

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