The facility received an immediate jeopardy citation in August after federal inspectors found clothing with dried brown substances, white and greenish-black unidentified matter, and overpowering smells of urine and mold. Regional Director of Clinical Operations P called the residents' personal clothing in the bin "horrible condition."
Housekeeper R told inspectors on August 16 she had never seen residents' personal clothes in the large green bin before that day. The clothes had been mixed with facility linen and returned by the commercial laundry company, which only cleaned the nursing home's bedding and towels, not residents' personal items.
The facility's former Housekeeping Supervisor, who resigned August 8, revealed the scope of the laundry crisis during a phone interview. She said clothes often returned from the local laundromat "smelling like urine and stained with poop" even after washing. When Housekeeper V couldn't get items clean, they were bagged separately and returned to storage containers to be rewashed later.
Nobody tracked how long clothes sat unwashed.
The former supervisor had warned administrators that washing heavily soiled nursing home laundry at a coin-operated facility was "not a good idea." The laundromat water wasn't hot enough to sanitize contaminated items, and the facility purchased only basic household detergent with no bleach or disinfecting chemicals.
Administrator admitted on August 20 he knew proper chemicals and water temperatures were required for resident laundry but said, "I don't know what the temperatures were at the laundromat."
A local laundromat owner with commercial infection control experience confirmed the facility's approach was dangerous. Water at coin laundromats typically reaches 140-142 degrees Fahrenheit, far below the 160 degrees required for nursing home laundry. He said he would refuse service to any long-term care facility because his washers weren't equipped to prevent infection spread.
The Tennessee Department of Health's Infection Prevention Specialist warned that inadequately cleaned laundry could spread clostridium difficile, a highly contagious bacteria causing severe diarrhea. "If heavily soiled/contaminated laundry was taken to a laundromat, there is a concern that temperatures and chemicals would not be sufficient to kill bacteria, viruses, fungi, or even parasites," the specialist wrote.
The laundry system collapsed when new management took over May 1, 2024. The previous commercial laundry service ended April 30, forcing administrators to improvise. They decided residents' soiled clothing would be transported to a coin laundromat three times weekly.
CNA U described the haphazard process: dirty clothes from all residents were thrown together in a single white rolling hamper marked "Personal Laundry," then bagged and stored in blue plastic containers in an outdoor building. Residents had no individual laundry containers in their rooms.
During the facility's COVID-19 outbreak from June 18 to August 7, isolation laundry was supposed to be placed in red or yellow biohazard bags. But Housekeeper V told inspectors she didn't remember washing any clothes in colored bags and wasn't sure "where the isolation laundry went."
The COVID outbreak exposed even more serious infection control failures.
Twenty-two residents contracted COVID-19, including several with severe cognitive impairment who couldn't understand their illness. Resident #2 developed a high fever and headache before testing positive June 24. Resident #33, who has autism and dementia, told staff he felt "not feeling well" after his positive test June 19.
The facility allowed COVID-positive employees to continue working, violating Centers for Disease Control guidelines that require infected healthcare workers to isolate for at least seven days with negative tests before returning. The facility's own policy, dated May 2023, contained outdated guidance that inspectors said should have been updated to reflect current CDC recommendations.
CDC guidance published in March 2024 clearly stated healthcare personnel with COVID-19 symptoms must stay home for at least seven days and test negative within 48 hours before returning to work. For asymptomatic cases, workers need negative tests on consecutive days before ending isolation.
The facility's Production Manager at their commercial linen service expressed shock when contacted about the laundry situation. "I was shocked to learn the facility was taking items to a laundromat to wash," he said, noting that "certain chemicals have to be used" for proper sanitization.
On August 16, as inspectors documented the contaminated clothing, Administrator scrambled to find solutions. He called Housekeeper V to see if she could work that day to take clothes to the laundromat, and contacted the commercial linen service to ask if they could handle resident laundry.
CNA T, who had never been asked to transport soiled laundry before August 16, drove the facility van to the storage building where she and the Administrator removed moldy clothes from the green bin and placed them in plastic bags.
Inspectors found 12 additional bags of residents' soiled laundry stored in the blue containers, confirming that clothes had been accumulating for months without proper cleaning.
The facility also failed to post required Enhanced Barrier Precautions signage on three resident rooms during the inspection, creating additional infection risks.
Administrator acknowledged on August 21 that he had been informed April 28 the facility would lose laundry service for residents' personal items effective April 30. "The facility had to put something in place," he said, describing the decision to use the local laundromat starting May 1.
Federal inspectors removed the immediate jeopardy citation August 21 after the facility agreed to use their commercial linen service for resident laundry. The Production Manager confirmed the first "batch" of properly cleaned resident clothing was completed August 20.
The facility's 90 residents had been living with inadequate laundry services for more than three months while administrators knew the coin laundromat couldn't provide proper sanitization. During that same period, 22 residents contracted COVID-19 in an outbreak that might have been contained if infected employees had been properly excluded from work.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rocky Top Care Center from 2024-08-22 including all violations, facility responses, and corrective action plans.