Unsanitary Kitchen Floor Drain: A kitchen floor drain was observed with a buildup of debris and grime, and the Kitchen Mgr confirmed it was dirty and could spread contamination. The Mgr stated floor cleaning was the responsibility of Maintenance, and the Maint Mgr later confirmed the drain had not been recently cleaned and was not sanitary. The facility policy required strict sanitary conditions in Dietary and Nutrition to prevent food contamination and growth of disease-producing organisms.
Laundry staff were not aware of the PPE available for sorting dirty laundry. During observation, no face shields or goggles were seen in the sorting area, and a laundry aide stated her apron was at home, the gloves were on the wall, and she used reading glasses instead of eye protection. The DON later stated the expectation was that aprons not be taken home and that face shields be available for eye protection, while the facility policy required laundry staff to handle linens to prevent spread of infection.
Infection control failures occurred when staff caring for residents on COVID-related precautions cleaned goggles for only 90 seconds before placing them with clean PPE, and an OT wore a surgical mask instead of an N95 in a resident's room. An LPN also handled a glucometer without a barrier, placed it on a resident's overbed table, and returned it to the med cart drawer without cleaning it first.
A resident who was discharged and later tested positive for Legionella at a hospital was not properly followed up by facility staff. The IP Nurse received notification from the hospital but did not document the call, gather key details, or initiate required infection surveillance actions such as water testing or resident tracking. The case was not reported to the Health District, and the Administrator was not informed, contrary to facility policy.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A review found that the facility's Water Management Plan lacked specific measures and procedures to prevent and monitor the growth of Legionella and other waterborne pathogens. While water temperature was monitored, the plan did not include detailed processes for disinfection of shower heads, flushing of infrequently used outlets, or assign responsibility for these tasks.
A resident with an indwelling urinary catheter and an active bladder infection was observed with their catheter bag resting on the floor while seated in a wheelchair. Both an LPN and the DON confirmed that facility policy requires catheter bags to be kept off the ground to prevent contamination, but this protocol was not followed.
The facility did not enforce or document its Legionella Water Management Program as required, with no evidence of regular monitoring or review prior to being notified of possible Legionella contamination. Two residents with complex respiratory and cardiac conditions tested positive for Legionella after being transferred to acute care, and the facility could not provide documentation of required water system inspections or control measures before the incident. The water management plan was found to be adequate but had not been periodically reviewed or tailored to the facility, and documentation of compliance only began after external notification.
A CNA entered a room under Enhanced Barrier Precautions (EBP) to assist a resident with an ESBL urinary tract infection without performing required hand hygiene, despite clear signage and available alcohol-based hand rub. This action was observed by an RN and confirmed by facility leadership as a violation of policy.
Staff failed to properly disinfect a shared glucometer with EPA-approved wipes, did not consistently perform hand hygiene or use PPE when entering rooms of residents on contact isolation for C. diff and wound infection, and did not document required education for visitors regarding isolation precautions. These lapses involved both staff and visitors and affected multiple residents with infectious conditions.
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