F0880

F

Inadequate Infection Control Practices and Water Management Program

Lenox, Iowa Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in the facility’s infection prevention and control program, including improper use of Enhanced Barrier Precautions (EBPs), incorrect wound care practices, and an incomplete water management program. For one resident with heart failure, diabetes, COPD, intact cognition, and an indwelling urinary catheter, the MDS and care plan documented the need for EBPs due to the catheter and directed staff to use gowns and gloves during high-contact care such as transfers, toileting, and catheter care, with hand hygiene before and after care. Surveyors observed that although an EBP sign was posted on the resident’s door and staff wore gloves, two CNAs transferred the resident with a mechanical lift, handled the catheter, removed the resident’s pants and brief, placed a bedpan, and later performed pericare and catheter site cleansing without wearing gowns during these high-contact activities, contrary to the facility’s EBP policy.

For another resident with diabetes, peripheral venous insufficiency, lymphedema, and diabetic ulcers on the toes of the left foot, the care plan and TAR directed daily wound care using Vashe solution, betadine, and gauze dressings. During an observed wound treatment, an RN donned mask, gown, and gloves and brought a dressing supply cart into the resident’s room, despite the resident being on EBPs. The RN opened saline bottles and cart drawers, obtained gauze, and performed skin fold and groin cleansing, then removed soiled dressings from the resident’s left foot, cleansed and treated the wounds, and applied new dressings. Throughout the procedure, the RN repeatedly opened and closed cart drawers and handled supplies on the cart with contaminated gloves, placed tape on top of the cart, moved an isolation gown in the drawer, retrieved a pen from a uniform pocket, and wrote on tape while using the cart surface, then returned supplies to the drawers. The RN also placed a soiled pad and towel on top of the cart, later removed the gown and put it in the trash on the side of the cart, and then pushed the same cart to another room and handled the soiled pad and towel again. These actions conflicted with the facility’s wound care policy requiring use of a disposable barrier for supplies and prohibiting return of disposable supplies to the cart, as well as the infection control and hand hygiene policies requiring proper handling of equipment, soiled linens, and glove use with hand hygiene when moving from dirty to clean areas.

The facility also lacked a comprehensive and effectively implemented water management program to control Legionella and other waterborne pathogens. The Maintenance Director reported not knowing the location of the water flow diagram, who was responsible for Legionella preventive procedures, or which parts of the building were supplied by the two water heaters. Review of facility blueprints did not identify the service areas for each water supply line or the locations of high-risk stagnant water areas. The Housekeeping supervisor stated that staff flushed sinks and toilets during deep cleaning but that this task was not included on the deep clean checklist, and the checklist itself did not list toilet or sink flushing. The Administrator reported that a whirlpool near the DON’s office was temporarily nonfunctioning and believed it was the last water-supplied device in that hall’s water supply sequence. An annual Legionella environmental assessment documented the presence of a whirlpool without filter change or backwash documentation and a fish aquarium maintained at 77°F without a maintenance protocol, with the last cleaning date noted. These findings did not align with the facility’s water management policy, which required annual assessment of the water system to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and to specify interventions and monitoring when risks were identified.

The infection prevention and control policy stated that all staff were responsible for following infection control policies and procedures, that equipment must be cleaned and disinfected per facility policy, and that soiled linen should be collected at the bedside, placed into a linen bag, and then taken to a soiled utility room. The handwashing/hand hygiene policy emphasized that glove use does not replace hand hygiene and that integrating glove use with routine hand hygiene is best practice for preventing infection spread. During interviews, the ADON confirmed that EBPs are used to prevent the spread of germs and protect residents and staff, acknowledged that the dressing supply cart should not have been taken into a room for a resident on EBPs, and agreed that the RN had touched drawers and items on the cart with contaminated gloves, contrary to expectations that staff change gloves and sanitize hands when soiled or when moving from dirty to clean areas. The Administrator later acknowledged that the facility could have done better at implementing the water management plan.