ROCKY TOP, TN - Federal inspectors discovered moldy, foul-smelling residents' clothing stored in unsanitary conditions at Summit View of Rocky Top, while the facility simultaneously failed to properly isolate COVID-positive staff members during a devastating outbreak that infected 22 residents.
The Tennessee Department of Health cited the 90-bed nursing home for immediate jeopardy violations during an August 2024 inspection, revealing a catastrophic breakdown in basic infection control practices that put vulnerable residents at severe risk.
![Summit View of Rocky Top nursing home exterior]
Residents' Clothing Found in Deplorable Condition
Inspectors made a shocking discovery in a storage building behind the facility: a large green bin filled with residents' soiled clothing covered in dried brown substances, urine stains, and white and greenish-black unidentified materials. The clothes were described as "stiff" and "rigid" with a musty odor that made them difficult to handle.
"The residents' personal clothing in the large green bin was in horrible condition," stated the Regional Director of Clinical Operations during the inspection.
The contaminated laundry represented months of accumulated clothing from approximately 85 residents. Staff revealed that after the previous housekeeping supervisor resigned on August 8, 2024, no one had been properly managing the residents' personal laundry system.
Dangerous Laundromat Processing System
The facility had implemented a makeshift laundry system in May 2024 that violated basic healthcare sanitation standards. Staff transported residents' contaminated clothing to a local coin-operated laundromat three times per week, using only household-grade detergent without proper sanitizing chemicals or adequate water temperatures.
The former housekeeping supervisor revealed critical flaws in this system: "Sometimes the laundry would be brought back to the facility smelling like urine and stained with poop after it had been washed."
Water temperatures at commercial laundromats typically reach only 140-142 degrees Fahrenheit, far below the CDC-recommended minimum of 160 degrees required for healthcare facilities. The facility used standard household laundry detergent without bleach or other disinfecting agents necessary to eliminate pathogens.
Medical Implications of Improper Laundry Handling
Healthcare facilities require specialized laundry processing because nursing home residents are particularly vulnerable to infections. Their compromised immune systems, open wounds, and underlying medical conditions make them susceptible to bacteria, viruses, and fungi that can survive inadequate cleaning processes.
The Tennessee Department of Health's Infection Prevention Specialist warned that improperly processed contaminated laundry could harbor dangerous organisms including Clostridium difficile, a highly contagious bacteria that causes severe diarrhea and can be life-threatening for elderly residents.
Proper healthcare laundry processing requires high-temperature washing (minimum 160°F), antimicrobial chemicals, and specialized handling procedures to prevent cross-contamination. The facility's laundromat system provided none of these protections.
COVID-19 Outbreak Mismanagement
Concurrent with the laundry crisis, Summit View failed to properly manage a COVID-19 outbreak that infected 22 residents between June 18 and August 7, 2024. The facility allowed COVID-positive employees to return to work before completing required isolation periods, directly violating CDC guidelines.
The infected residents included individuals with severe cognitive impairments and underlying conditions like Alzheimer's disease, dementia, and chronic respiratory diseases - populations at highest risk for severe COVID-19 complications.
Federal guidance required healthcare workers with mild to moderate COVID-19 symptoms to remain out of work for at least 7-10 days with negative test results, or receive two consecutive negative tests 48 hours apart. The facility's premature return-to-work decisions created an immediate jeopardy situation for all 90 residents.
Breakdown in Basic Infection Control
The violations revealed systematic failures in infection prevention practices. Residents' contaminated clothing was mixed together in communal containers without individual separation, creating cross-contamination risks. Staff handling soiled laundry often lacked proper protective equipment, with some workers not wearing gowns or aprons while processing contaminated materials.
The facility also failed to post required Enhanced Barrier Precautions signage on three resident rooms, leaving staff and visitors unaware of necessary protective measures.
Industry Standards and Required Protocols
Proper healthcare laundry processing requires: - Water temperatures of at least 160°F for minimum 25 minutes - Use of chlorine bleach or oxygen-activated antimicrobial agents - Separation of contaminated items by risk level - Proper bagging and transportation procedures - Staff training on infectious disease prevention
COVID-19 isolation protocols mandate: - Minimum 7-day isolation with negative test results before return to work - Universal masking during outbreak conditions - Immediate testing of exposed residents and staff - Consultation with public health authorities
Administrative Response and Corrective Actions
The facility's administrator acknowledged awareness that proper chemicals and water temperatures were required for washing residents' laundry but admitted uncertainty about laundromat specifications. "I don't know what the temperatures were at the laundromat," he stated during the investigation.
Following the immediate jeopardy citation, the facility contracted with a TRSA-certified commercial laundry service to properly process residents' clothing. The commercial service's Production Manager expressed shock at learning the facility had been using a laundromat, noting that "certain chemicals have to be used" for healthcare laundry.
Immediate corrective measures included: - Transitioning to professional healthcare laundry services - Implementing proper COVID-19 isolation protocols - Installing required Enhanced Barrier Precautions signage - Staff retraining on infection control procedures
Ongoing Compliance Concerns
While inspectors validated removal of the immediate jeopardy on August 22, 2024, the facility remained cited for ongoing infection prevention violations. The scope and severity of the violations demonstrate systemic deficiencies in management oversight and staff training that required comprehensive remediation.
The case highlights the critical importance of proper infection control systems in healthcare facilities, where vulnerable populations depend on rigorous sanitation practices to prevent life-threatening complications.
Federal regulations require nursing homes to maintain comprehensive infection prevention programs specifically because residents face heightened risks from communicable diseases and contamination. The Summit View violations represent a fundamental failure to protect residents' health and safety through basic hygiene and disease prevention measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Summit View of Rocky Top from 2024-08-22 including all violations, facility responses, and corrective action plans.
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