Hand hygiene was not performed by staff while serving meals and assisting residents in the dining room, with a Social Service Assistant and an Activities Assistant observed handling meals and resident needs without washing or sanitizing their hands. In the laundry room, HSKP staff sorted soiled linen without full PPE, and clean bolster pads, microfiber cloths, dust mops, and clean mop heads were stored on the soiled side of the room near contaminated laundry, contrary to facility policy.
The facility failed to maintain infection control practices on two nursing units and for one resident. A clean linen cart was stored in a resident’s bathroom beside an unflushed toilet with feces, an in-use shower mat was torn and the shower gurney underneath was soiled with matter and hair, and a resident’s nebulizer mask was left improperly stored on the bedside table instead of being kept in a sanitary manner.
Staff failed to follow infection control practices when gloves were worn in the hallway and a resident’s Foley drainage bag was found on the floor under an over-bed table and excessively full. A CNA stated the bag should have been hanging on the bed frame and needed to be emptied, while other CNAs confirmed gloves should not be worn in hallways. The facility’s policy required Standard Precautions, including hand hygiene and proper PPE use.
Failure to Follow Contact Precautions for a Resident with CRPA: An RN entered a resident’s room wearing gloves only and exposed the resident’s enteral feeding tube site despite contact isolation orders and a posted sign requiring a gown and gloves. The resident had severe cognitive impairment, chronic respiratory failure with hypoxia, quadriplegia, ventilator dependence, and a respiratory culture positive for CRPA; the care plan and facility policy both required contact precautions.
Incomplete Infection Surveillance Tracking: The facility failed to maintain a complete IPC tracking program because the infection logs reviewed only tracked infections requiring antibiotics and did not include viral infections or symptom-based tracking for infections not requiring antibiotics. The DON/IP stated she had not been keeping any other tracking log, although resident symptoms were reviewed when reported by staff, and the market clinical lead said a separate line listing was available but no additional logs were provided.
Two residents on contact isolation or Enhanced Barrier Precautions (EBP) did not receive care in accordance with posted PPE requirements and facility policy. One resident with MRSA and multiple antimicrobial-resistant infections had contact isolation and EBP signage and an isolation cart with PPE at the door, yet an LPN entered and remained in the room without donning a gown or gloves, despite acknowledging the resident’s contact isolation status. Another resident on EBP related to a condom catheter had door signage directing staff to wear gowns and gloves for direct care, but a CNA twice provided dressing assistance and peri-care while wearing only gloves and no gown, later stating he had forgotten to don the gown. The DON confirmed the first resident should have been on contact isolation with gowns and gloves used upon room entry, and the Infection Preventionist confirmed that EBP was not appropriate for the first resident and that staff are expected to use gowns and gloves for residents on EBP during direct care, consistent with the facility’s EBP policy.
The facility failed to maintain infection control practices for two residents. One resident with Influenza B had droplet/contact precautions ordered, but an Activities Assistant entered the room wearing only a mask and a CNA entered with no PPE despite the posted precaution sign. Another resident with dry eye syndrome received eye drops from an LPN, who used the same tissue to wipe both eyes instead of using separate tissues as required by policy to prevent cross contamination.
A resident’s nasal cannula tubing and CPAP mask were observed on the floor on two occasions, rather than stored in a clean, covered manner as required by facility policy. A CNA reported finding the equipment on the floor at the start of her shift and stated she had informed the charge nurse and requested appropriate storage supplies. An RN and an LPN both acknowledged the equipment should not be on the floor and should be kept in labeled bags, while the DON stated the resident was known to remove his oxygen and was unaware that the tubing on the floor was attached to an oxygen concentrator used at bedtime. The facility’s respiratory care policy requires safe storage, covering of oxygen cannulas and masks when not in use, and clean, labeled storage for CPAP equipment, which was not followed in this case.
A resident with an indwelling foley catheter, neurogenic bladder, CKD, and a history of UTIs was observed in a wheelchair with the catheter drainage bag dragging on the floor. The resident’s record included an order for monthly catheter changes and a care plan noting UTI risk and the need for foley care; the IP later agreed the catheter should not have been touching the floor.
Infection control practices were not followed during wound care for a resident with a right shin skin tear. An LPN touched the room light switch, moved personal items, placed clean wound supplies on an unclean overbed table, handled the trash can, and continued wound care without proper hand hygiene or glove changes between dirty and clean tasks. The RN unit manager, infection preventionist, and DON stated that hand hygiene and glove changes were expected during wound care, and the facility policy required a disinfected overbed table, a clean field, and hand hygiene throughout the procedure.
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