A facility failed to maintain infection control practices for a resident using nebulizer treatments and for two residents during meal assistance. A resident’s nebulizer equipment was observed dry and unbagged when not in use, despite policy requiring storage in a plastic bag, and an LPN confirmed it should have been bagged. During lunch, a CNA assisted two residents with eating using the same hand without hand hygiene between residents and wiped both residents’ mouths without gloves or hand hygiene; the RNC confirmed hand hygiene should have been performed when switching between residents.
Failure to Implement Enhanced Barrier Precautions: The facility failed to ensure EBP were implemented and maintained for 7 of 32 residents with chronic wounds or indwelling medical devices. Surveyors observed no EBP in use during multiple facility observations, and no EBP policy was provided. The IP stated the facility had stopped using EBP after an update was received, and the DON said she misunderstood CMS guidance and believed EBP was no longer required.
Infection control practices were not maintained for respiratory equipment, shared equipment, and laundry handling. A resident’s CPAP mask and another resident’s CPAP mask were left uncovered, a nebulizer was left unbagged and visibly soiled, a shared vital sign machine had visible splatter, and staff handled wet underpads, dirty linens, and personal clothing in ways that placed items on the floor or transported them without protective covering.
The facility failed to follow infection control practices involving hand hygiene, glucometer disinfection, oxygen equipment storage, and linen handling. A CNA did not offer hand hygiene before a resident ate, nurses stored glucometers after wiping them with sanitizer or an alcohol swab instead of disinfecting them after each use, a resident’s nebulizer equipment was left uncovered, clean linens were transported with the cart cover not down, and PPE such as gowns and eyewear was not being used or available at the hoppers.
Hand hygiene and glove change practices were deficient when an RN performed a glucose finger stick on a resident with clean gloves, removed the dirty gloves, and put on clean gloves without performing hand hygiene. The resident had type 2 DM, HTN, and chronic pain syndrome. The IP stated hand hygiene should be performed when changing gloves and when moving from a dirty environment to a clean environment.
Infection control and hand hygiene practices were not followed during resident care for multiple residents. An LPN applied topical treatment and then handed a resident a mouth moisturizer without removing dirty gloves or cleaning hands, a CNA performed incontinence care and handled clean supplies without changing gloves or performing hand hygiene, and an RN began wound care after touching the bed controls and linens without being observed performing hand hygiene or changing gloves; enhanced barrier precautions were also not followed during wound care for one resident.
A facility failed to maintain infection control practices when residents in multiple rooms were served breakfast without being offered hand hygiene beforehand, despite a Dining Room policy requiring staff to encourage handwashing or sanitizing before each meal. A CNA later stated residents should have been offered hand hygiene and that staff are supposed to carry a large bottle of hand sanitizer to clean residents' hands.
The facility failed to maintain infection control practices for respiratory equipment and laundry handling. Two residents had nebulizer mouthpiece and tubing left uncovered on bedside tables, clean bed linens were observed being carried down the hallway uncovered, and staff stated the linens should have been bagged. In the laundry rooms, staff reported CNAs washed laundry and did not always use goggles or aprons, while multiple washers, dryers, vents, and surrounding surfaces had visible buildup. The DON and Administrator also stated there was no cleaning schedule for the personal washers or dryers.
Infection control practices were not followed when an LPN handled a glucometer and wound care supplies without proper hand hygiene or barrier protection, placed equipment and supplies on resident bedside tables, and returned a glucometer to storage without sanitizing it. An LPN also used dressing supplies from another resident during wound care and did not perform hand hygiene before or after glove changes. In addition, the Maintenance Director stated the facility had eight swamp coolers on the roof but had never tested them for Legionella.
Staff failed to consistently implement and follow Enhanced Barrier Precautions (EBP) during wound care for two residents. For a resident with an indwelling urinary catheter and an EBP order, an RN and a CNA removed their gowns after catheter care and performed a heel and toe dressing change wearing only gloves, despite a door sign requiring gown and gloves for wound care and other high-contact care. For another resident with multiple open leg wounds and active wound care orders, an RN and a nurse aide performed dressing changes with gloves only, without gowns, and there was no EBP signage or order in place. Interviews with nursing staff, the IP, and the DON revealed inconsistent understanding and application of the facility’s EBP policy, which requires gown and gloves for high-contact care activities, including wound care and device care, for residents with chronic wounds or indwelling devices.
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