Housekeeping staff failed to follow infection control practices while cleaning resident rooms. In one room, a housekeeper cleaned the sink and toilet area without hand hygiene or glove changes when moving between dirtier and cleaner areas, did not wait the required dwell time for the toilet disinfectant, and did not clean high-touch items such as light switches, door handles, the call light, or closet handles. In another room, a housekeeper used the same gloves and rag across the sink area, closet door and handles, bed area, bedside table, and resident personal items. Leadership and the IP confirmed that staff should clean from cleaner to dirtier areas, perform hand hygiene and glove changes, and clean high-touch surfaces during room cleaning.
Infection control practices were not maintained when housekeepers cleaned sink areas out of sequence and used the same rag on cleaner and dirtier surfaces, a water management program for Legionella was not in place and testing supplies were unavailable, and CNAs moved a vitals cart between residents without disinfecting the blood pressure cuff or machine between uses. The IP and DON stated that reusable equipment should be cleaned between residents.
The facility failed to maintain infection control practices during room cleaning, EBP care, and access to the soiled linen room. Housekeepers did not consistently disinfect high-touch surfaces, did not keep BNC-15 wet for the required dwell time, did not use proper glove and hand hygiene practices, and did not follow cleaning procedures in shared rooms and bathrooms. CNAs also provided incontinence care, transfers, showers, and care for residents with catheters and tube feeds without the required gowns under EBP, and residents were observed entering the soiled linen room and looking through bagged soiled linens.
An infection control deficiency occurred when an LPN failed to perform hand hygiene during medication pass, reused a spoon after tablets spilled on a table, and moved from one resident to another without sanitizing hands. An RN did not disinfect vital signs equipment between two residents, portable oxygen canisters were stored on the floor, a CPAP mask was left out instead of being stored properly, and an LPN continued wound care after retrieving a marker from a pocket without changing gloves or performing hand hygiene.
The facility failed to maintain infection control practices during wound care, medication administration, and equipment disinfection. An RN did not follow EBP during wound care, brought a treatment cart into resident rooms, placed supplies on unclean surfaces, and did not perform hand hygiene between glove changes. An LPN also failed to perform hand hygiene between residents during med pass, and staff did not keep disinfectant wet long enough on a glucometer and vital signs equipment to meet the required dwell time.
Housekeeping staff failed to follow infection control procedures while cleaning resident rooms and bathrooms. In two observed rooms, staff did not keep disinfectant wet for the required dwell time, used the toilet brush beyond the toilet bowl, and missed multiple high-touch surfaces such as call lights, door knobs, light switches, grab bars, and bed controls. Interviews confirmed staff knew the correct process, including the need for a three- to five-minute wet contact time and daily disinfection of high-touch areas.
Staff failed to follow infection control practices during resident care and meal assistance. An CNA and an LPN did not don PPE while obtaining vital signs for residents on EBP, vital signs equipment and personal devices such as a pulse oximeter and stethoscope were used without being sanitized between resident use, and CNAs did not perform hand hygiene between assisting multiple residents with meals in the dining room.
The facility failed to maintain infection control practices when staff used the same sit-to-stand lift for multiple residents without disinfecting it between uses and did not perform hand hygiene after resident contact. CNAs also returned blood pressure cuffs to medication carts without cleaning them after use on residents. In addition, a housekeeper repeatedly donned and doffed gloves while cleaning resident rooms without hand hygiene, including when moving between rooms and handling cleaning tasks.
Failure to Follow EBP and Keep Catheter Equipment Off the Floor: An LPN and a respiratory therapist did not wear gowns during high-contact care for residents with an indwelling urinary catheter and a tracheostomy, despite EBP requirements for residents with indwelling medical devices. In addition, urinary catheter drainage bags and tubing for two residents were observed on or dragging along the floor, including under a wheelchair and beneath a bedside table wheel.
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.
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