A resident with a left shin wound and cellulitis was not placed on EBP despite facility policy indicating EBP for residents with wounds and requiring a gown for wound care. During observed wound care, no EBP signage was posted at the room entrance and the RN did not wear a gown while applying ordered mupirocin and changing the dressing. The DON confirmed the resident should have been on EBP.
An LPN used shared blood pressure equipment on one resident, placed it back near the med cart without wiping it, and then used the same equipment on two other residents without disinfecting it between uses. The IP stated shared medical equipment must be cleaned with disinfecting wipes between uses, and the facility policy required shared equipment to be cleaned and disinfected before and after use on another resident.
A pill cutter in the station 1C med cart was observed with large amounts of white and brown sediments inside it during survey. An RN administering meds from the cart confirmed the contamination and stated it was from not cleaning the cutter, adding that it should be cleaned after each use.
A facility failed to maintain infection control in a supply room and during wound care for a resident with a stage 4 sacral PU. Clean ice for resident use was stored near a sink used for handwashing and resident water, staff food and fluid items were kept in the same area, and the ice cooler blocked access to the paper towel dispenser while staff washed hands. During wound care, an RN cleaned the wound area but did not change gloves or perform hand hygiene before applying the foam dressing, and the DON confirmed the lapse.
The facility failed to consistently implement its infection prevention and control program, including proper use of contact precautions, Enhanced Barrier Precautions (EBP), and hand hygiene. A resident with C. difficile was cared for by staff and visited by a visitor who did not follow required gown, glove, and soap-and-water handwashing protocols, despite posted signage and facility policy. During meal service and medication administration, a CNA and an RN moved between residents and care tasks without performing hand hygiene between contacts or between glove changes. Two CNAs provided bathing and hygiene care to a resident under EBP without wearing required gowns, and in another EBP room, a resident handled a roommate’s trash bin and urine-filled urinal, discarded trash in the soiled utility room, and returned the urinal without being prompted by an LPN to perform hand hygiene afterward.
Failure to use PPE for residents on contact precautions: Staff were observed providing care to two residents on TBP without wearing gowns or gloves. An AA assisted a resident at bedside and leaned close while communicating, and CNAs assisted another resident with meals on separate occasions without the required PPE. NS and RN staff confirmed both residents were on contact precautions, and the facility policy required a disposable gown upon entering the room and removal before leaving.
Surveyors found that the facility did not complete the required annual review and evaluation of its infection prevention and control plan. Policy language in the plan requires an annual assessment of all components for compliance, trends, and continued applicability, but document review showed the last review occurred more than a year prior. During interviews, the IP initially could not state when the plan was last reviewed and later confirmed that the most recent review was the prior year and that the plan was only then under review, resulting in a cited deficiency at the facility-wide infection control program level.
Staff failed to follow infection control practices during meal service when a Dietary Staff member served lunch to seven residents in a common area without performing hand hygiene between residents. The facility policy for meal service called for hand hygiene as appropriate, and the IP confirmed staff are to perform hand hygiene when moving from one resident to another to prevent possible spread of infections.
Surveyors identified multiple infection control failures, including two residents with indwelling urinary catheters whose drainage tubing was observed lying on the floor, with one resident’s tubing visibly discolored and containing sediment and associated complaints of itching and leakage. Nursing staff acknowledged the tubing should not be on the floor and that the soiled tubing should have been addressed, while a CNA performed catheter care for a resident on Enhanced Barrier Precautions wearing only gloves and no gown, with PPE stored down the hall rather than immediately outside the room as required by facility policy. The facility’s Legionella water management plan, which called for high hot-water setpoints, routine temperature monitoring, flushing, and review of logs, was not being implemented, with only lower temperature logs available and the new IP reporting no active control measures or collaboration with maintenance. In addition, trash bags were repeatedly left piled outside the trash bin and on an exterior stairwell landing, with housekeeping staff relying on a maintenance worker with the only key to the bin and reporting delays in trash being placed inside, resulting in obstructed access and unsanitary trash accumulation.
Failure to Review Infection Prevention Policies Annually: The facility failed to ensure its IPCP was reviewed annually. During an interview, the IP reviewed internal policy records and confirmed that the Hospital-Wide Infection Prevention plan, LTC Antimicrobial Stewardship Program, and Infection Surveillance and Prevention policies had not been reviewed within the required 12-month timeframe, and the RCQCO was made aware of the lapse.
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