The facility failed to follow infection control practices after a complaint and surveyor observations found dirty meal trays, dried brown liquid, a stained pillow, and food debris in resident areas. Multiple bathrooms had unlabeled basins, bedpans, fracture pans, and urine collection items stored on floors, under sinks, or on toilets without plastic wrapping, and one bathroom had a fly on the toilet rim. The Chase Unit TV room also had numerous spills, crumbs, paper towels, cups, food pieces, and trash on the floor. The IP stated the facility did not have a policy for storing these items.
Failure to Follow Enhanced Barrier Precautions: Two staff entered a resident’s room with enhanced barrier precautions in place without using hand sanitizer before entry and were observed touching the bed, sheets, air mattress, and air mattress device. Later, an LPN and the unit manager again entered without hand hygiene, and the in-room sanitizer dispenser was found not to dispense when tested by the surveyor. One staff member gave no explanation, and the other said he forgot and would pay more attention next time.
Cross Contamination During Linen Processing: A laundry aide processed soiled linens with PPE, then doffed her washable gown, hung it beside the sink, and went to the clean side of the laundry room to fold clean linens without performing hand hygiene. The issue was observed and discussed with the aide and the account manager, and the aide acknowledged the lapse.
An LPN took a treatment cart into a resident’s room after the resident fell and was found diaphoretic, despite the facility’s practice of keeping treatment carts out of resident rooms for infection control reasons. The Infection Preventionist confirmed this was not the normal practice and said the action was unacceptable.
Infection prevention and control practices were not maintained on a nursing unit when a bag of linen was found on the floor in a resident room, 2 bags of soiled linen/trash were observed on the hallway floor outside resident rooms, and a clean linen cart was left uncovered. GNAs, an LPN, and the ADON all stated the clean linen cart should be covered and that soiled linen and trash should not be stored on the floor in rooms or hallways.
Failure to follow standard precautions and EBP was observed during resident care and equipment handling. A CMA used the same portable BP machine and cuff on two residents without disinfection between uses, and a CNA provided care to a resident on EBP without wearing a protective gown despite an EBP sign posted on the door. Staff also handled a spill with bare hands before touching clean-area surfaces and supplies, and the IP stated staff are expected to perform proper hand hygiene.
The facility failed to follow its Legionella remediation plan and local health department guidance after positive water testing in resident rooms. Staff reported that resident room showers were not to be used and were not routinely flushed, but surveyors found several showers still operational and flushing logs were incomplete. The IP stated residents with respiratory symptoms were not tested for Legionella unless they had a pneumonia diagnosis, despite guidance for enhanced surveillance. Surveyors also found no designated handwashing sinks in the soiled laundry rooms, improper use of the utility sink for multiple tasks, and a damaged hopper labeled out of order.
An LPN and NP failed to use clean technique during wound care for a resident with multiple wounds, including a pressure wound and a suprapubic catheter site. Supplies were placed on a cluttered overbed table without a clean field or barrier, the same gloves were used throughout dressing changes, hand hygiene and glove changes were not performed between dirty and clean tasks, and a catheter bag was handled in a way that caused urine to flow back into the tubing.
A resident ordered on EBP for CRE, a foley, wound care, and enteral feedings did not have the required gown used during wound care. During observation, the Wound Care NP did not wear the yellow isolation gown required for high-contact care, and the DON acknowledged that PPE should be worn for this resident’s high-contact care.
Clean Linen Area Not Kept Free of Dust: The facility failed to keep the clean linen room free of dust. Surveyors observed an uncovered AC vent opening, dust on the wall above the linen folding table, and dark dust in a corner near an unused vent while clean blankets, top sheets, and fitted sheets were on the table. The EVS Director said staff are supposed to clean the area daily but were unsure when it was last dusted.
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