F0880

F

Widespread Infection Control and Water Management Failures

Canton, Ohio Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures in the facility’s infection prevention and control practices during resident care, medication administration, blood glucose monitoring, and environmental management. For one resident with pneumonia, muscle weakness, impaired cognition, and dependence on staff for toileting, a CNA was observed providing care with the room door open while soiled linens and a used adult brief were left on the floor. The CNA acknowledged that the dirty linens and brief were on the floor and stated she would pick them up after finishing care. The DON later confirmed that dirty linens were not to be placed on the floor and should be put in a bag.

For residents with diabetes, staff did not follow hand hygiene and equipment disinfection policies during blood glucose monitoring and insulin administration. One cognitively intact resident with type 2 diabetes and acute kidney failure had an order for twice-daily blood sugar checks. An LPN removed a glucometer from the medication cart, entered the resident’s room, performed a fingerstick blood sugar check without cleaning the glucometer before use, then briefly wiped it with an alcohol pad afterward. The LPN returned the glucometer to the cart without performing hand hygiene before or after the procedure and confirmed that the device was used on multiple residents daily and that she had not cleaned it before use or washed her hands. Another resident with type 2 diabetes and chronic kidney disease, who received daily insulin, had a fingerstick blood sugar check and insulin administration performed by a different LPN who never washed her hands or used hand sanitizer before, between, or after entering and exiting the room. This LPN placed the glucometer on top of the cart, handled multiple insulin pens, administered insulin, then briefly wiped the glucometer for about 12 seconds before returning it to the cart, and confirmed she had not performed hand hygiene and believed this was the correct way to clean the glucometer. These practices did not follow the facility’s handwashing and cleaning/disinfecting policies or the Sani Wipe instructions requiring a two-minute wet time.

Additional hand hygiene failures occurred during medication administration for residents with significant functional impairments. One severely cognitively impaired resident with radiculopathy, diabetes, and muscle weakness required assistance with ADLs. An LPN prepared 12 oral medications from the cart without hand hygiene, administered them along with a nasal spray, then returned the nasal spray to the cart without washing her hands before or after resident contact or before reentering the cart. Another cognitively intact resident with Parkinson’s disease and chronic kidney disease, who required ADL assistance, received 10 medications prepared in applesauce by a different LPN who also did not wash her hands before preparing the medications, after administering them, or before accessing the cart again to prepare medications for the next resident. These actions were inconsistent with the facility’s handwashing policy requiring hand hygiene before and after resident care and invasive procedures.

The facility also failed to follow Enhanced Barrier Precautions (EBP) for a resident with severe cognitive impairment, a chronic sacral wound, and an indwelling catheter, who was care planned for EBP due to chronic wounds and device use. Two CNAs provided high-contact care, including a brief check and change, emptying the catheter bag, disconnecting and reconnecting catheter tubing, draining urine, dressing the resident, and transferring the resident via mechanical lift, without donning isolation gowns and without performing hand hygiene before, during, or after care. One CNA acknowledged the presence of an EBP sign at the room entrance instructing staff to wear gloves and a gown for high-contact activities such as transferring and device care, and both CNAs confirmed they had not worn gowns or performed hand hygiene. These actions did not comply with the facility’s EBP and handwashing policies.

In addition to direct care issues, the facility did not implement its Legionella Water Management Program as written. The Administrator confirmed that in one year the facility only tested ice machines and did not perform required Legionella testing of the broader water system, and in the following year no Legionella testing was completed at all. The Administrator further confirmed that the facility used city water and that, despite contacting the water company, no Legionella testing was performed. The Administrator also acknowledged that there were empty resident rooms with private bathrooms and sinks where water could remain stagnant and that these areas were not tested in either year. These practices did not align with the facility’s Legionella Water Management Program policy, which required identification and monitoring of areas in the water system where Legionella could grow and spread, including storage tanks, water heaters, filters, aerators, showerheads, hoses, misters, humidifiers, and fountains, and required at least annual review of the program.