A CMA and a CNA provided high-contact care to a resident on EBP while wearing gloves but no gowns, and they did not perform hand hygiene each time they removed gloves. The resident had intact cognition, quadriplegia, kidney stones, and a nephrostomy tube, and her care plan required gowns and gloves for high-contact care such as repositioning, hygiene, changing linens, and device care.
Staff failed to follow infection control practices during resident care, medication administration, and meal service. An LPN used an uncleaned pulse oximeter from a smock pocket, an RN and LPN did not consistently perform hand hygiene before and after glove use, a dietary aide touched ready-to-eat food with bare hands, and staff caring for a resident on EBP did not properly remove PPE or bag potentially contaminated laundry before leaving the room.
Infection control practices were not followed during resident care and use of shared equipment. A CNA moved a mechanical lift after a resident transfer without hand hygiene, CNAs did not consistently perform hand hygiene before or after PPE use, and staff were unclear about required PPE when rinsing soiled linens in the hopper. In addition, whirlpool room hygiene items were not kept clean, as opened, donated, reused, and refilled personal care bottles were used for residents.
Expired hand sanitizer was found in many resident rooms, a linen cupboard lacked a covering to protect linens from airborne infectants, and a resident’s wheelchair had torn, dirty padding. Staff also failed to consistently follow EBP and hand hygiene during personal hygiene and wound care for residents with pressure ulcers, including not cleansing a wound before dressing it and bringing wound care supplies into multiple rooms without sanitizing equipment between residents.
A CNA failed to follow EBP infection control practices while providing hygiene care and a transfer for a resident with an indwelling urinary catheter, using a soiled glove to take Aquaphor from a jar and handling the catheter bag above bladder level without clean gloves. Two housekeepers also failed to change gloves when moving from dirty tasks, such as cleaning toilets, to clean tasks while cleaning resident rooms. Interviews and policy review confirmed that gloves, gown use, hand hygiene, and catheter positioning were expected.
Staff failed to follow infection control practices during resident personal care and catheter care. CNAs and an RN used the same gloves across dirty and clean tasks, touched resident personal items and bedside surfaces after perineal care, and did not clean catheter tubing during one resident’s care. Reusable mechanical lifts were also observed with debris, damaged surfaces, and missing parts, and were returned to the hallway without being disinfected after resident use.
Urinary catheter bags for a resident with a kidney transplant, CKD, and urinary retention were observed stored in the resident’s bathroom shower without caps over the tubing connectors and without dates showing when they were last used. One bag was on a shower bench and another was hanging on a handrail near a toilet, and a syringe used for cleaning was also present. Staff and the IP confirmed that an uncapped bag stored next to a toilet would be considered contaminated, and the facility policy did not clearly define when the cleaning syringe should be changed or who should do it.
A CNA wore two pairs of gloves while assisting a resident with incontinent care and, with potentially soiled gloves, touched the resident’s wardrobe and retrieved clean clothing before removing the gloves. The CNA said this was a normal practice at the facility and confirmed she did not remove the outer gloves after peri-care. The DON stated this was not the facility’s normal practice and that staff were expected to remove soiled gloves and perform hand hygiene before touching clean clothes or the wardrobe; the PPE policy did not address double-gloving, and the hand hygiene policy required hand hygiene after glove removal.
Failure to Follow EBP and Hand Hygiene Practices: Staff did not wear gowns or gloves, did not perform hand hygiene, and did not clean an EZ stand lift after providing high-contact care to a resident on EBP with a Foley catheter. Staff also provided toileting care to a resident with open stage II pressure ulcers without gowns, and a housekeeper handled resident-room surfaces and items with unclean hands while cleaning rooms. Facility policy required gown and glove use for EBP, cleaning reusable equipment between residents, and hand hygiene after resident contact and glove removal.
A resident with urinary retention, bladder disorder, and a suprapubic catheter was ordered to have twice-daily catheter flushes with normal saline and 5% vinegar. An LPN reported reusing a labeled graduated cylinder for the irrigation solution while only changing the syringe, despite facility policy requiring sterile equipment and the availability of sterile catheter kits. The DON acknowledged the container should be changed each time and that the resident had experienced UTIs, while a nurse manager training as the infection preventionist was unaware non-sterile cylinders were being used. The administrator stated the LPN had been educated on catheter kits and that nurses should understand sterile field requirements.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.