Staff failed to follow hand hygiene and infection control practices during peri-care, wound care, and med pass. During resident care, staff wore the same soiled gloves while moving between dirty and clean tasks, handled clean supplies and personal items, touched equipment and body areas, and removed PPE without sanitizing hands. During med prep and administration, an LPN and other staff handled meds, cups, devices, and carts without proper hand hygiene before, after, or between residents, contrary to the facility’s hand hygiene policy.
EBP was not identified or initiated for residents with wounds, a skin lesion, or an indwelling Foley catheter, as signage was missing and PPE was not readily accessible at the point of care. In addition, a staff member distributing clean linen entered multiple residents’ rooms and handled clean clothing without performing hand hygiene before entering, after exiting, or before touching clean linen.
Failure to maintain the facility water management program led to a resident being diagnosed with Legionnaires' disease. Staff reported the facility relied on weekly toilet flushing in unoccupied rooms and weekly water temp checks, but its Legionella prevention practices were not following public health guidance when the resident became ill and was later hospitalized with acute hypoxic respiratory failure related to Legionnaires' disease.
Infection Control Lapses in Glucose Testing and Laundry Area Cleanliness: A staff member performing BG testing left a resident’s room with contaminated gloves, handled shared glucose-monitoring supplies with those gloves, and contaminated the test strip bottle with blood before cleaning it off. In the laundry room, detergent buckets sat on the floor with open hose gaps, and the washer area had lint, debris, and buildup on lids, walls, washer tops, hinges, and door seals.
Staff failed to follow infection control practices during ostomy care and peri-care for a resident with an ostomy, including missed hand hygiene and improper glove use. During med pass for a resident with DM, staff did not disinfect the glucometer with the required EPA wipes and did not perform hand hygiene after glove removal. Staff also did not use the required gown and mask PPE during care for a resident on EBP who had a groin wound and suprapubic catheter, and staff interviews showed confusion about EBP requirements.
Improper hand hygiene and glove use during medication pass were observed with two residents. An RN/LPN entered one resident's room without hand hygiene, handled the Rover and medication cards, prepared oral meds, and gave a B-12 injection after donning gloves without first cleaning hands. In another resident's room, a staff member prepared and administered meds, removed and applied patches, and changed gloves without hand hygiene before or after glove use, including after touching dirty equipment and before applying patches to clean skin areas.
Infection control practices were not followed during meal service and resident care. A staff member served a resident from a cup with a crusted substance on it, and another staff member touched her hair and pockets while setting up and serving trays without hand hygiene. During care for a resident with wounds and fecal incontinence, staff mixed clean and soiled linens, left a Hoyer lift uncleaned, and moved from one wound to another without removing gloves or performing hand hygiene between wounds.
A resident with a chronic Foley catheter was observed with the drainage bag on the floor while staff administered meds, despite facility policy requiring the bag and tubing to be kept off the floor. Another resident who was dependent on continuous O2 was observed with nasal cannula tubing that was not dated, and the MAR/TAR showed no documentation of tubing changes. Staff gave inconsistent statements about how often O2 tubing should be changed and how it should be documented.
The facility failed to keep infection control policies and the reportable communicable disease list current. Staff reported that the infection control program and policies had not been reviewed recently, and record review showed outdated policies for influenza immunization, pneumococcal immunization, and ASP, along with an infection control prevention policy last updated well before the survey. The facility also used an old communicable disease reporting list dated years earlier instead of the current county health department list.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
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