Infection control failed when a housekeeper cleaned a resident bathroom and handled her cart, mop bucket, and mop heads without changing gloves or performing hand hygiene after cleaning the toilet. Two shower rooms had missing drain covers, leaving open holes in the floor. Two soiled utility rooms also had infection control issues, including a large pile of filled biohazard trash bags and a hopper with water and visible green and brown film.
An LPN provided wound care for a resident on EBP without donning a gown. Housekeeping staff cleaned resident toilets out of order and did not finish cleaning the toilet bowl in a sanitary manner. An RN failed to maintain sterility during trach suctioning and dressing care, and a CNA alternated meal assistance between two dependent residents without hand hygiene between residents.
Hand hygiene was not maintained during wound care for two residents. A wound doctor contaminated his gloves by touching non-sterile items, then continued wound cleansing, photography, debridement, and dressing application without changing gloves or cleaning his hands between dirty and clean tasks. He also entered a resident room, handled sterile supplies, and changed gloves without hand hygiene. Staff interviews confirmed that hand hygiene was expected between glove use and between dirty and clean wound care steps.
Catheter Bag Left on Floor: A resident with an indwelling catheter was observed multiple times with the catheter bag touching or lying on the floor, including while seated in a wheelchair and while in bed. The bag was also seen without a privacy cover at times, and an LPN and the DON stated catheter bags should be kept below the bladder and off the floor for infection control and dignity purposes.
Infection Control Failures in Room Cleaning and Disinfection: Housekeeping staff were observed cleaning resident room sinks, toilets, bedside tables, and high-touch surfaces in a manner that did not follow hygienic sequence or the Virex dwell time. Staff used the same cloth across cleaner and dirtier areas, wiped a toilet seat after cleaning the bowl rim, and removed disinfectant before the required wet contact time. Interviews showed inconsistent understanding of proper disinfection and high-touch surface cleaning.
Infection control failures occurred when housekeeping staff did not follow proper room-cleaning procedures, including cleaning high-touch areas, changing gloves, and performing hand hygiene between tasks. A housekeeper cleaned a resident room without cleaning the sink first or sanitizing the call light, and another housekeeper moved through multiple cleaning tasks without changing gloves or cleaning hands. An LPN also failed to keep an Oxivir wipe wet for the required dwell time on a blood pressure cuff and reused the cuff on another resident without disinfecting it between residents.
Infection control failures were observed during housekeeping and med pass activities. A housekeeper cleaned resident room toilets and moved between tasks without proper hand hygiene, handled trash and then continued cleaning, and did not allow disinfectant to remain on toilet surfaces. An RN picked up a dropped tablet from the floor with bare hands and continued med administration without hand hygiene. The facility also had multiple heavily soiled sink drains and buildup in common area, staff, therapy, and resident room sinks, and its water management plan did not document steps for other opportunistic pathogens.
Staff failed to follow infection control precautions for a resident on EBP, a resident on contact and droplet TBP for rhinovirus, and housekeeping cleaning procedures for high-touch surfaces. CNAs entered a resident’s room for catheter care without gowns, a CNA delivered meals to a resident on TBP without hand hygiene or PPE, and housekeepers did not keep disinfected surfaces wet for the required dwell time or clean all high-touch items such as call bells.
Glucometers Not Disinfected After Resident Use: Surveyors observed an RN, the ADON, and another RN perform blood glucose checks on residents and then place the glucometers into resident-labeled plastic bags without cleaning or disinfecting the devices first. The facility policy required glucometers to be cleaned and disinfected after each use, and staff acknowledged they should have disinfected the meters after each use.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
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