Failure to Implement Effective Infection Control and Water Management Program
Summary
The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria. The deficiency was identified after a resident, who was bedbound, ventilator-dependent, and had not left the facility for over two weeks, became unresponsive and was hospitalized with septic shock and pneumonia. The resident subsequently tested positive for legionella pneumophila antigen and died in the hospital. Review of the facility's water management documentation revealed significant gaps, including the absence of updated control measures for areas affected by flooding and closure, lack of detailed plumbing schematics, and insufficient documentation of water system maintenance, flushing, and monitoring. There was no evidence that the water management plan had been revised to address changes in the physical plant, such as the closure of the Somerset unit after flooding, nor was there a written description of how water was supplied, heated, stored, or circulated throughout the building. Observations and interviews further revealed that water stagnation and potential sources of contamination were not adequately addressed. For example, the Somerset unit, which had been closed after flooding, still had water running to certain areas, and there were no logs or documentation to confirm that water lines were being flushed to prevent stagnation. In addition, the attic area above the affected resident's room showed signs of mold, water damage, a decomposed animal carcass, and leaking pipes, all of which were verified by maintenance staff. These environmental conditions, combined with the lack of clear signage and communication to staff regarding water restrictions and infection control measures, contributed to the risk of legionella exposure. The facility's infection control practices were also found lacking in other areas. For instance, a respiratory therapist was observed providing suctioning and tracheostomy care to a resident in contact isolation for Clostridium difficile infection without wearing appropriate personal protective equipment. This failure to adhere to standard infection control protocols had the potential to affect multiple residents on the same unit. Overall, the facility's inaction and insufficient oversight in both water management and general infection control practices led to the identified deficiencies.
Removal Plan
- Registered Nurse (RN) #431 notified the Medical Director, Administrator, Director of Nursing (DON) and Infection Control Physician of the Legionella case.
- Administrator, DON, Assistant Director of Nursing (ADON) and Human Resources instructed staff to avoid unflushed/restricted water and to use alternative (bottled or approved) water and ice.
- Administrator, Maintenance Director #368 and Dietary Director #317 implemented bottled water for all drinking and cooking.
- Use of ice machines, showers, whirlpool tub, hoppers were restricted on the Aspen unit and on the Birch, Dogwood, Crabapple units only bed baths with provided wipes were permitted as use of showers was restricted.
- Administrator, DON, ADON and Human Resources provided staff education to RNs, Licensed Practical Nurses (LPN), certified nursing assistants (CNA), Housekeepers, Activity staff, Respiratory Therapists (RT), and agency staff. The education included the Centers for Disease Control Legionella signs and symptoms, transmission, surveillance/detection, and the facility's water management program. For any staff not on the schedule due to leave or other reasons, education would be provided prior to start of next shift.
- DON and Registered Nurse (RN) #350 assessed all current residents for signs/symptoms of legionella infection (cough with phlegm, chest pain, fever, chills, and shortness of breath).
- Water was delivered to the facility by commercial provider.
- Bags of ice were delivered by commercial provider.
- Use of ice machine, sinks, showers, whirlpool tub, and hoppers were restricted on the remaining units of Birch, Crabapple, Dogwood and Somerset.
- A phone call was held with the local health department and Ohio Department of Health Bureau of Environmental and Radiation Protection for guidance on legionella mitigation and testing.
- Portable handwashing sinks were delivered and stationed on Aspen unit.
- Signage was posted by VPCS #806, RDCS #803, the DON, ADON and Respiratory Therapy Director instructing staff to avoid unflushed/restricted water and to use alternative (bottled/approved) water.
- ServPro performed professional attic cleaning on the Aspen unit including debris removal, HEPA vacuuming, antimicrobial treatment, stain/odor blocking sealant application, air/surface testing, removal of wet insulation, ceiling repair below the attic and vent pipe repair within the Aspen unit Hallway/Attic area between rooms 503, 508, 502, 509, 510 and 501.
- A phone call meeting was held with a legionella consultant to review the facility water management plan.
- Portable handwashing stations were delivered and stationed throughout the facility.
- Maintenance Supervisor (MS) #368 installed legionella prevention filters on the Aspen unit (in the shower room, medication room and rooms 501, 502, 503, 504, 505, 506, 507, 509, 510, 515, 516, 517, 518 and 519).
- Regional Director of Operation completed Somerset unit water flush which included full flushing of all pipes, bathrooms, sinks, hoppers and dialysis den. Documentation was submitted to the Administrator.
- An Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the Medical Director, VPCS, RDO, RDCS, Administrator, DON, MDS, Housekeeping, MS #368, Human Resources, RN #431 and the ADON for QAPI tracking including weekly flushing compliance, audit outcomes, symptom surveillance, environmental concerns, legionella water management program review and risk assessment analysis review.
- MS #368 installed additional legionella prevention filters to two hand sinks in dialysis, one hand sink in the therapy gym, one hand sink in the first floor public rest room, one hand sink in laundry and six sinks in the kitchen, one sink in the Birch, Dogwood, Crabapple medication rooms, one sink in the first floor dining room, one sink in the Dogwood shower room and the Crabapple room sinks in rooms 710, 716 and 718.
- RDO re-educated MS #368 on weekly flushing, documentation rules, proper procedures (15 minutes run time, full toilet flush/hopper flush) and reporting/escalation steps.
- RDO contacted an additional Legionella Consultant #901 for mitigation support.
- Legionella Consultant #901 performed water testing of samples collected across Aspen, Birch, Crabapple, Dogwood and Somerset units.
- The facility implemented a plan for clinical monitoring by the DON/ADON or designee to review resident documentation weekly for four weeks for symptoms such as temperature, pulse, respirations, blood pressure, oxygen level, lung sounds, cough and phlegm, chest pain, fever/chills, shortness of breath.
- The facility implemented a plan for environmental monitoring by the Administrator or designee to review flushing logs weekly for four weeks and monthly thereafter.
- The facility implemented a plan for enhanced surveillance by the DON/ADON to include enhanced respiratory illness monitoring and immediate reporting of suspected cases.
- The facility implemented a plan for the water management program to be on-going and include daily monitoring of temperature, disinfectant levels, flushing logs, legionella filters for placement and function twice a day and monthly Water Management Plan meetings until investigation closed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Staff failed to consistently implement and follow Enhanced Barrier Precautions (EBP) during wound care for two residents. For a resident with an indwelling urinary catheter and an EBP order, an RN and a CNA removed their gowns after catheter care and performed a heel and toe dressing change wearing only gloves, despite a door sign requiring gown and gloves for wound care and other high-contact care. For another resident with multiple open leg wounds and active wound care orders, an RN and a nurse aide performed dressing changes with gloves only, without gowns, and there was no EBP signage or order in place. Interviews with nursing staff, the IP, and the DON revealed inconsistent understanding and application of the facility’s EBP policy, which requires gown and gloves for high-contact care activities, including wound care and device care, for residents with chronic wounds or indwelling devices.
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
The facility failed to fully document infection surveillance and RTW decisions during a COVID outbreak. Multiple staff members reported symptoms such as sore throat, headache, congestion, diarrhea, vomiting, fever, and cough, but the employee illness logs were incomplete and left the RTW date blank, with no indication they were tested for COVID or cleared per CDC guidance. At the same time, multiple residents were diagnosed with COVID and others had GI symptoms with unknown testing status. The IP said she worked infection control only a few hours per week and had not thoroughly reviewed the logs for trends, while the DON had not been reviewing the surveillance logs.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Infection Control Failures During Resident Care: Staff did not follow PPE, hand hygiene, and equipment-cleaning practices during care for several residents. An RN failed to clean a glucometer and basket after blood sugar checks, a CNA and a Central Supply staff member entered rooms with enhanced barrier precautions without PPE, and an LVN did not clean the glucometer or insulin vial, and did not properly perform hand hygiene during insulin administration and after emptying a urinal. Residents involved had significant cognitive impairment, diabetes, wounds, and other serious diagnoses.
Infection control failed during laundry services when staff reported using the same personal T-shirt for handling dirty laundry and then hanging clean laundry, while using disposable gowns only for laundry from a resident with an infection. The DON also acknowledged that the Infection Prevention Program policy was overdue for annual review, and the policy showed no indication of an annual review.
Failure to Implement and Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use and implementation of Enhanced Barrier Precautions (EBP) during wound care. One resident with an indwelling urinary catheter had an active order and care plan for EBP, and a door sign specifying that gown and gloves were required for high-contact resident care activities, including wound care and device care. During an observation, an RN and a CNA entered this resident’s room, performed hand hygiene, donned gown and gloves, and completed catheter care in accordance with the posted EBP instructions. However, after completing catheter care, the RN instructed the CNA that they could remove their gowns because EBP was “only for the catheter,” and both staff removed their gowns and gloves, performed hand hygiene, and then donned only clean gloves to perform a dressing change on the resident’s right heel and pinky toe, despite the door sign indicating gown and gloves were required for wound care. A second resident had multiple open wounds on both lower extremities that required cleansing, application of collagen with wound gel and alginate, and coverage with border gauze dressings. Progress notes documented that these wounds originated as skin tears and were slowly healing, and active wound care orders were in place. During an observation of wound care for this resident, an RN and a nurse aide performed hand hygiene and donned gloves but did not wear gowns. There was no EBP sign or PPE set up outside the room, and there was no order for EBP in the electronic medical record, even though the resident had open wounds requiring dressing changes. In interviews, the RN stated that EBP was required for chronic wounds such as pressure, venous, and arterial wounds, and that EBP for the first resident applied only to catheter care. The CNA reported that she relied on the door sign and believed she only needed to gown for catheter care, brief care, or toileting, and not for transferring if she was not in contact with the catheter. The Infection Preventionist explained that EBP was used for chronic wounds and indwelling devices and stated that staff would only need to gown when providing care to the Foley catheter, while the DON stated that EBP was for residents with devices or dressing changes to prevent MDROs and that staff should wear gown and gloves even when not providing direct catheter care. The facility’s written EBP policy specified that EBP applies to residents with chronic wounds and/or indwelling medical devices and that PPE for EBP is necessary when performing high-contact care activities, including wound care and medical device care, which was not consistently followed in the observed wound care encounters.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Incomplete COVID Surveillance and Return-to-Work Tracking
Penalty
Summary
The facility failed to ensure its infection prevention and control program documented employee illness monitoring, testing, and return-to-work decisions during a COVID outbreak. The report states that 7 of 9 staff members with symptoms of COVID were not documented as having been tested, their illnesses were not tracked to identify possible links between resident COVID cases and staff exposure or subsequent illness, and there was no indication when they could return to work according to CDC guidance. The January 2026 resident infection surveillance log showed 12 residents diagnosed with COVID during the outbreak and exhibiting symptoms including cough, runny nose, congestion, and wheezing. Five additional residents had loose stools and vomiting, but it was unknown whether they had been tested or found positive for COVID. The January 2026 employee illness log showed multiple staff call-ins for symptoms including sore throat, headache, congestion, dizziness, lightheadedness, diarrhea, vomiting, fever, sinus congestion, and cough, but the logs were not completed fully and the date returned to work was left blank each time. The infection preventionist stated she had been in the role for less than a year, worked infection control only 4 to 5 hours per week depending on staffing, and transferred staff illness information from the business office into the employee illness logs. She said staff were to be off work for at least 24 hours after vomiting, fever, or diarrhea resolved, but she had not thoroughly completed the surveillance logs or looked for trends or patterns. The DON stated she reviewed the IP's monthly data before QAPI meetings but had not been reviewing the surveillance logs since the new IP started. The facility's infection control and surveillance policies described monitoring infections for trends and managing infections through education and record keeping, and the return-to-work policy included guidance for suspected or confirmed COVID, but the report states there was no indication this return-to-work process followed CDC guidance.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for multiple residents during observed care and record review. Resident #7 had a diagnosis of type 2 diabetes mellitus and a BIMS score of 4, indicating severely impaired cognition. During an observation, RN A used a small amount of hand sanitizer for only a few seconds, checked the resident’s blood sugar, and did not clean the glucometer before placing it in the medication cart. RN A also used a purple basket to carry glucometer supplies into the resident’s room, placed it on the bedside table, and did not clean the basket before returning it to the medication cart. RN A stated the glucometer should be sanitized before and after each use and that not doing so could put the resident at risk of infection. Resident #32 had severe cognitive impairment and multiple injuries, including intracerebral hemorrhage, subarachnoid hemorrhage, fractured rib, fractured lower leg, fractured spine, and surgical and traumatic wounds. The care plan included enhanced barrier precautions. During observation, the resident’s room had an enhanced barrier precautions sign and the PPE station outside the door had only one glove and one gown. CNA A assisted with removing a brace from the resident’s right arm without using any PPE. CNA A stated that any time there was a PPE station, staff were supposed to use the PPE and that failing to do so could transfer something to another resident. Resident #95 had diagnoses including breast cancer, Asperger’s syndrome, protein-calorie malnutrition, anxiety, and hypokalemia, and the care plan directed staff to use gown and gloves during high-contact care activities that could transfer MDROs. During observation, the resident’s door had an enhanced barrier precautions sign, but staff entered the room without PPE while Central Supply assisted with pulling the resident up in bed. Central Supply stated PPE was required any time patient care was provided to the resident. Resident #101 had type 2 diabetes mellitus and an insulin order for lispro before meals for high blood sugars. During observation, LVN D did not perform hand hygiene before putting on gloves, did not clean the glucometer before checking the resident’s blood sugar, did not clean the top of the insulin vial before withdrawing insulin, performed hand hygiene for less than 5 seconds and did not cover the backs of her hands, and did not properly perform hand hygiene after emptying the resident’s urinal. LVN D also did not clean the glucometer or tray before placing them in the medication cart.
Infection Control Lapses in Laundry Services and Policy Review
Penalty
Summary
The facility failed to ensure appropriate infection control during laundry services and failed to review its Infection Prevention Program policy annually. During a laundry room tour and interview, other staff stated they put a personal T-shirt on over their clothes when handling dirty laundry and used the same T-shirt when hanging clean laundry. They also stated they used disposable gowns when handling laundry from a resident with an infection, but had no concerns about wearing the same clothing for clean and dirty laundry if the resident did not have an infection. The director of maintenance stated the facility used an external company for on-site laundry and housekeeping services and believed laundry staff wore gloves and a gown when handling dirty laundry, but was not concerned if no gown was worn as long as staff clothing did not touch the dirty clothing. The Bywood East Infection Control and Prevention Program policy dated 4/26/24 had no indication of an annual review, and the DON stated the infection prevention program policy was overdue for review.
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