Sewage flooded the second-floor hallway, resident rooms, and bathrooms, with wastewater also leaking into a first-floor office. Video and interviews showed staff laying towels and sheets across the corridor to soak up the sewage while confused residents and wheelchair users moved through the contaminated water, and one resident reported sewage backing up from toilets and shower drains with urine and feces in the water.
Infection control was not maintained when a resident wore the same clothing protector after using the bathroom and returning to eat, a CNA picked up another resident’s nasal cannula from the floor and placed it back on the resident without sanitizing it, and a Hoyer lift was used between two residents without being sanitized in between. The DON stated the oxygen tubing should have been replaced, the resident should have received a new clothing protector, and the lift should have been wiped down between uses.
Failure to use EBP PPE during high-contact care. An RN administered meds through a resident’s NG tube without a gown, and a CNA Coordinator assisted another resident with a G-tube during repositioning and meal assistance while wearing gloves but no gown. The IP stated that EBP required gowns and gloves for residents with feeding tubes and for high-contact care activities.
Failure to implement EBP for two residents with chronic wounds and wound-related care needs. One resident with a chronic foot ulcer and another resident with multiple open skin areas and chronic leg, shoulder, and buttock wounds had no EBP signage or PPE available in their rooms, and staff interviews showed inconsistent understanding of the EBP orders. CNAs reported providing care with only gloves or without gowns, while the RDCS confirmed both residents should have been on EBP with gown and glove use for high-contact direct care.
Infection control was not maintained for two residents. An RN removed an oxycodone tablet from a blister pack, then placed it back after the resident refused it. During wound care for another resident with bilateral AKA stumps and a left stump wound, hand hygiene was not performed after glove changes, and the same gauze pad was reused multiple times to clean the wound bed. The DON and ADON stated these actions were not consistent with proper practice.
Hand hygiene was not consistently performed during meal service, with CNAs observed touching residents and surfaces, delivering trays, and repositioning residents without changing gloves or cleaning hands. EBP was not implemented as ordered for residents with indwelling devices, as PPE and signage were missing or not used consistently, and staff showed inconsistent understanding of gown, glove, and mask requirements. The facility also stored PPD solution in a medication refrigerator at temperatures below the manufacturer’s required range, making the TB screening process for new admits inaccurate.
Infection control deficiencies were identified involving a resident on EBP for wound care, a meal-time cross-contamination event between two residents, and an uncapped tube feeding setup for a resident receiving enteral nutrition. Observations and staff interviews showed missing EBP signage and PPE at the resident’s door, a resident using a fork already used to feed herself to mix butter into another resident’s food, and disconnected feeding tubing left uncapped while formula remained in the bag. The DON and IP described the facility’s infection control protocols for EBP, meal assistance, and capping disconnected feeding tubing.
The facility failed to document an annual review of its IPCP. The Infection Prevention and Control Policy stated the plan would be reviewed annually and updated as needed, but when the DON was interviewed, documentation showing the last review was requested and not provided.
Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
A resident with chronic wounds and multiple comorbidities received wound care without EBP, with staff entering without gowns, failing to perform hand hygiene at key points, and cleansing wounds in a back-and-forth manner across the wound bed. The dressing was not labeled and dated, and the facility also repeatedly transported uncovered coffee through the hallways to resident rooms during meal service.
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