Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
Penalty
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An LPN failed to follow infection control practices while preparing and administering medications to a resident with diabetes, vascular dementia, and CHF. The LPN handled an Ativan tablet with a bare hand while using a pill cutter and then administered Humalog insulin subcutaneously after cleansing the injection site but without donning gloves, contrary to facility policy requiring glove use for injectable medications.
Surveyors found that staff failed to follow infection control practices during incontinence care for a resident who was frequently incontinent and dependent on staff for care. Two CNAs washed their hands before care, and one CNA properly removed soiled gloves and performed hand hygiene after cleansing the perineal area. However, the second CNA cleansed the resident’s buttocks, then, without changing the now soiled gloves or performing hand hygiene, obtained and applied a clean brief. Hand hygiene and glove removal occurred only after the brief was in place. The CNAs and the DON acknowledged that gloves should have been changed and hand hygiene performed before handling the clean brief, as required by facility policy and CDC guidelines.
Surveyors found that the facility did not follow its Enhanced Barrier Precautions policy for two residents with invasive devices. One resident with a gastric feeding tube had tube feeding performed without gowns or gloves available in or outside the room, and no EBP orders were in place despite signage requiring gown and glove use for feeding tube care. Another resident receiving IV antibiotic therapy via a PICC/midline for pyothorax had IV medication administered by the DON, who used hand hygiene and gloves but did not don a gown or other required PPE, and the resident was not placed on EBP despite qualifying under facility policy.
The facility failed to maintain proper infection control when toothbrushes for two residents who required staff assistance with oral hygiene were stored without protective barriers. One resident had neurologic and mobility-related conditions, and another had dementia, chronic respiratory failure, and joint disease, with documentation showing dependence on staff for oral care. During observation of their shared bathroom, a toothbrush was found resting directly on a paper towel dispenser, and multiple toothbrushes were placed on the sink without barriers, stacked on another toothbrush and toothpaste. An LPN acknowledged that the toothbrushes were not stored to prevent potential contamination.
Surveyors found that the facility did not carry out or document required Legionella control measures, including routine flushing of infrequently used water outlets and scheduled cleaning or replacement of shower heads, despite having a written water management plan and CDC guidance. In addition, enhanced barrier precautions (EBP) ordered for residents with abdominal wounds, tracheostomies, and diabetic foot ulcers were not followed: an LPN and an RN performed wound and trach care without gowns, without disinfecting bedside tables before placing supplies, and without appropriate hand hygiene between glove changes, and staff assisted a resident with a chronic foot wound in ADLs and transfers without PPE or EBP signage or supplies available, contrary to facility policy and physician orders.
Staff failed to follow required infection control practices for shared glucometers used for blood glucose monitoring. An LPN used a single uncovered glucometer stored in a medication cart drawer on multiple residents without cleaning it before use, and only briefly wiped it with an alcohol pad afterward. Another LPN also used the same type of shared glucometer on multiple residents, wiping it with alcohol pads for only a few seconds and wrapping it in dry tissue between uses. Facility leadership confirmed that Super Sani Germicidal wipes were the designated product, and manufacturer instructions required specific cleaning and disinfection steps with those wipes after each patient use, with alcohol wipes not listed as an acceptable option.
Failure to Follow Infection Control Practices During Medication and Insulin Administration
Penalty
Summary
The deficiency involves failure to follow infection prevention and control procedures during medication administration for one resident. The resident was admitted with diagnoses including type 2 diabetes, vascular dementia, and congestive heart failure, and had impaired cognition with a BIMS score of 4/15, requiring staff assistance with ADLs. Physician orders included Humalog insulin via sliding scale with meals for diabetes and Ativan 0.5 mg by mouth every 4 hours while awake for severe agitation related to vascular dementia. During a medication pass observation, an LPN removed an Ativan tablet from the medication card, placed it into a medication cup, then poured it into a pill cutter and used an ungloved hand to reposition the tablet in the center of the pill cutter before cutting it and placing half the tablet into the medication cup. The same observation showed the LPN then prepared and administered the resident’s Humalog insulin based on a blood sugar reading of 240, which required 5 units per the sliding scale order. The LPN sanitized her hands, cleansed the resident’s right lower abdomen with an alcohol pad, injected the insulin, and wiped the area with another alcohol pad, but did not don gloves at any time during the insulin administration. In a subsequent interview, the LPN confirmed that she had repositioned the Ativan tablet with an ungloved hand and had not worn gloves while administering the insulin, and acknowledged that gloves should have been worn during medication preparation and insulin administration. Review of the facility’s “Injectable Medications” policy dated 06/21/17 showed a requirement to apply gloves prior to injecting medication, which was not followed in this instance.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow appropriate infection prevention and control practices during incontinence care for one resident. The resident had diagnoses including Parkinson's disease, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, benign prostatic hyperplasia, chronic kidney disease stage three, acute kidney failure, periodic limb movement disorder, disorder of the brain, anxiety disorder, and depression. A recent MDS assessment documented that the resident had intact cognition, was frequently incontinent of bowel and bladder, and was dependent on staff for incontinence care, with physician orders to check and change every two hours and as needed. The facility identified 45 residents who required incontinence care at the time of the survey. During an observed incontinence care episode, two CNAs washed their hands before beginning care. One CNA, wearing clean gloves, removed the resident’s soiled brief and cleansed the perineal area from front to back, then removed the soiled gloves, performed hand hygiene, and applied clean gloves. The resident was then rolled, and the second CNA, also wearing clean gloves, cleansed the resident’s buttocks area. Without changing the now soiled gloves or performing hand hygiene, this CNA then obtained a clean brief and placed it on the resident. Both CNAs removed their gloves and washed their hands only after the brief was applied. The CNAs and the DON confirmed that gloves should have been changed and hand hygiene performed after cleansing the buttocks and before handling and applying a clean brief, consistent with facility policy and CDC hand hygiene guidelines, which state that gloves should be changed and hand hygiene performed if gloves become soiled with blood or body fluids after a task.
Failure to Implement Enhanced Barrier Precautions for Residents With Feeding Tube and IV/PICC Line
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy and maintain appropriate infection prevention and control practices for residents with invasive devices. For one resident with severe dementia, metabolic encephalopathy, Alzheimer’s disease, essential hypertension, dysphagia, and a gastric feeding tube, surveyors observed a tube feeding procedure during which no personal protective equipment (PPE) was available either outside or inside the room, and no gown was worn. Staff confirmed that proper PPE was not worn, that no gowns or gloves were set up outside or inside the room, and that the resident did not have EBP orders in place, despite a sign on the door stating that staff must wear gloves and a gown for high-contact care activities including feeding tube care. Review of the medical record confirmed there were no physician orders for EBP for this resident. For another resident admitted with pyothorax and multiple comorbidities, including anemia, prosthetic heart valve, osteoporosis, nicotine dependence, convulsions, hyperlipidemia, depression, pleural effusion, hypothyroidism, mood disorder, atrial fibrillation, and generalized anxiety disorder, the plan of care documented a pneumonia-like condition related to empyema and ongoing IV antibiotic therapy. Physician orders included maintaining a midline IV, flushing the IV line with normal saline, assessing the midline site every shift, maintaining and changing the dressing, and administering daily IV Ceftriaxone Sodium for pyothorax. During observation of the DON administering IV Ceftriaxone via a PICC line, the DON washed her hands, administered oral medications, set up the IV medication, washed her hands again, donned gloves, flushed the line, and connected the medication, but did not don a gown or mask for EBP. In interview, the DON verified she had not used PPE for EBP and acknowledged the resident was not on EBP, although the resident should have been under the facility’s EBP policy, which requires gowns and gloves for residents with open routes to their interior body, including feeding tubes and IVs, and PPE stations set up with gowns and gloves outside or just inside the doorway.
Improper Toothbrush Storage Compromises Infection Control
Penalty
Summary
The deficiency involves the facility’s failure to ensure toothbrushes were stored in a manner that maintained infection control for two residents who required assistance with oral hygiene. One resident, admitted with diagnoses including dysarthria and anarthria, demyelinating disease of the central nervous system, and muscle weakness, had an ADL care plan indicating a need for assistance with oral hygiene. Another resident, admitted with diagnoses including dementia, chronic respiratory failure, and unilateral post-traumatic osteoarthritis of the left hand, also had an ADL care plan indicating a need for assistance with oral hygiene, and an MDS assessment documenting dependence on staff for oral hygiene. During observation of their shared bathroom, surveyors found a toothbrush resting directly on the bottom of a paper towel dispenser without a barrier, and two identical toothbrushes resting on the sink between the faucet and wall with no barrier, placed atop another different type of toothbrush and a bottle of toothpaste. In an interview, an LPN confirmed that the toothbrushes were not stored in a way that would prevent potential contamination. This deficiency represents non-compliance with infection prevention and control requirements as investigated under Complaint Number 2974213.
Failure to Implement Legionella Controls and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor its Legionella Water Management Plan and to follow its own policies and CDC guidance for Legionella control. The written plan, dated 12/01/25, required flushing hot and cold water for three to five minutes in empty rooms and less frequently used outlets, including soiled utility rooms, medication rooms, shower stalls, private room showers, and eyewash stations, as well as cleaning, disinfecting, or replacing shower heads on a six‑month cycle. Review of facility documentation showed no evidence that these flushing tasks or shower head maintenance were completed. The Maintenance Director stated that flushing of less frequently used outlets was performed and tracked in TELS but acknowledged he was unaware that documented evidence of task completion was required and confirmed that shower heads were not cleaned, disinfected, or replaced every six months as required by the plan. CDC Legionella control guidance reviewed by surveyors recommended maintaining hot water above 140°F and flushing low‑flow piping at least weekly and infrequently used fixtures regularly. The facility also failed to implement enhanced barrier precautions (EBP) for residents with wounds and indwelling devices as required by its own policies and physician orders. One resident with multiple diagnoses including bladder injury, septic shock, ascites, diabetes, and chronic kidney disease had an abdominal wound and a physician order for EBP during wound care. During observed wound care to the abdomen and closed‑suction bulb drain site, an LPN did not don a gown, did not disinfect the bedside table before placing wound care supplies on it, and did not perform hand hygiene between glove changes. The LPN and the Assistant DON confirmed these omissions and acknowledged that a gown should have been worn, the table disinfected, and hand hygiene performed between glove changes. Another resident with chronic respiratory failure, tracheostomy status, and dependence for all care had care plan interventions and physician orders for EBP every shift and tracheostomy care every 12 hours. During observed tracheostomy care, an RN did not perform hand hygiene before entering the room or between glove changes, did not don a gown, and did not disinfect the bedside table before placing sterile tracheostomy supplies on it; the RN confirmed these failures. A third resident with dementia, diabetes, peripheral vascular disease, and a diabetic foot ulcer had ongoing wound treatments to the left toes and heel, but no EBP were in place during observations of routine care and transfers, and CNAs providing ADL assistance wore no PPE. An LPN confirmed the resident had a current wound, that there was no EBP signage or accessible PPE outside the room, and that EBP should have been in place. The ADON later verified that EBP had not been implemented for this resident until the previous day, despite wound treatment orders being in place since late February. Facility policies required EBP, including readily available gowns and gloves, for residents with chronic wounds or indwelling medical devices and specified hand hygiene after glove removal.
Improper Cleaning and Disinfection of Shared Glucometers
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control practices when using shared glucometers. For one resident with type 2 diabetes mellitus, chronic kidney disease, and daily insulin orders, an LPN removed an uncovered glucometer from the top drawer of the medication cart, where it was lying on top of lancets, and used it to perform a fingerstick blood sugar test without cleaning it beforehand. The LPN stated there was only one glucometer on the cart used for all residents on her assignment and reported that she did not clean the glucometer on day shift because night shift cleaned them. After being questioned, she briefly wiped the front and back of the glucometer with an alcohol wipe for less than five seconds before returning it to the cart. For another resident with diabetes and daily insulin injections, an LPN similarly removed an uncovered glucometer from the top drawer of the medication cart, where it was also lying on top of lancets, and used it for a fingerstick blood sugar test. The LPN wiped the glucometer with an alcohol wipe before entering the room, then after use wiped it again with an alcohol wipe for less than seven seconds and wrapped it in dry tissue before returning it to the cart. The LPN confirmed the same glucometer was used for all residents on that assignment. The ADON identified Super Sani Germicidal Disposable wipes as the product to be used for cleaning the facility glucometers, and the manufacturer’s instructions for the specific glucometer required cleaning and disinfecting after each patient use with Super Sani wipes, including specific horizontal and vertical wiping steps and a two-minute wet contact time. The manufacturer’s instructions did not list alcohol wipes as an acceptable cleaning or disinfecting agent. The deficient practice was identified during a complaint investigation and affected two observed residents, with the potential to affect seven additional residents receiving blood sugar monitoring via glucometer.
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