The June inspection at Treasure Isle Care Center found multiple infection control breakdowns that put the facility's 136 residents at risk. Federal inspectors documented trash bags sitting on hallway floors and staff ignoring basic protective equipment protocols for one of the most concerning infections in healthcare.
Staff F, a registered nurse, entered Resident 136's room on June 11 without donning appropriate personal protective equipment. When stopped by the surveyor, the nurse acknowledged the mistake.
"No, according to the sign I am supposed to don gloves before I enter the room," Staff F told the inspector.
The resident had been under contact precautions since December 2022 for a history of candida auris. Physician orders from that date required contact precautions every shift. The resident's care plan, revised in October 2023, specifically listed contact precautions as an intervention.
Candida auris represents one of the most serious emerging threats in healthcare settings. The fungal infection spreads easily between patients and resists multiple antifungal medications. Healthcare facilities across the country have struggled to contain outbreaks once the organism establishes itself.
Resident 136's medical records showed a diagnosis of candidiasis upon admission. A quarterly assessment revealed the resident was dependent for all activities of daily living and had an undetermined cognitive status score.
The facility's infection control problems extended beyond individual rooms. Inspectors photographed trash bags sitting on hallway floors on two separate days during the survey.
On June 10 at 6:41 AM, a bag of trash was found on the floor in nursing section four, directly in front of a resident's room. Two days later at 12:18 PM, another trash bag was discovered on a hallway floor.
Staff G, who served as both charge nurse and infection control preventionist, explained the facility's waste disposal protocol to inspectors. Staff were required to take trash out of rooms in tied plastic bags, hold them away from their bodies without touching the floor, then place them in bins located in the soiled utility room.
The reality inspectors observed fell far short of these standards.
The facility's infection prevention policy, effective October 2021, outlined a comprehensive program to address detection, prevention and control of infections among residents, visitors and staff. The policy specifically mentioned implementing infection control measures through standard precautions, organism-specific precautions and appropriate barriers.
"Prevention of spread of infections is accomplished by use of Standard Precautions, organism specific precautions, and other barriers," the policy stated.
Yet when it mattered most, staff failed to follow these basic protocols.
Staff G confirmed to inspectors that personnel should perform hand hygiene and don all appropriate personal protective equipment before entering any room with contact precaution signs. The protocol existed. The training had occurred. The signs were posted.
The nurse walked in anyway without gloves.
During a quality assurance meeting on June 13, facility leadership discussed ongoing concerns with dignity and staffing. The director of nursing reported that education was ongoing for dignity issues. "Anything that occurs we educate the staff," the DON told inspectors.
For staffing, administrators explained they didn't use agency workers. Weekend coverage included adding a unit manager, while weekdays featured one unit manager per unit. "On the weekends we only have one supervisor because during the weekend we have more nurses," the DON revealed.
The nursing home administrator, assistant administrator and director of nursing were informed that the facility had concerns with its quality assurance and performance improvement program based on the identified violations.
The infection control failures at Treasure Isle Care Center highlight the gap between written policies and daily practice. Candida auris doesn't respect good intentions or comprehensive policies. It spreads through contaminated hands, equipment and surfaces when basic precautions break down.
Resident 136 remained dependent on staff for all daily care activities. Every interaction required trust that caregivers would follow protocols designed to prevent dangerous infections from spreading. That trust was broken when the registered nurse chose convenience over safety.
The trash bags on hallway floors represented another breakdown in infection control systems. Waste from resident rooms can harbor dangerous pathogens. Leaving it in common areas where staff, visitors and mobile residents might encounter it creates unnecessary exposure risks.
Federal inspectors classified the violations as causing minimal harm with potential for actual harm. The designation reflected that while no residents were documented as being harmed by these specific incidents, the failures created conditions where serious infections could spread.
The facility's quality assurance program, designed to identify and correct such problems before they compromise resident safety, had failed to prevent these basic infection control breakdowns. Monthly meetings with department heads hadn't translated into consistent adherence to safety protocols where residents were most vulnerable.
Staff G's dual role as charge nurse and infection control preventionist placed responsibility for both patient care and infection prevention in the same hands. The arrangement meant the person setting infection control standards also worked directly with residents under those protocols.
The violations occurred during routine care activities when staff might feel most comfortable cutting corners. No emergency existed. No crisis demanded immediate attention. A nurse simply chose not to put on gloves before entering a room clearly marked for contact precautions.
Resident 136's history with candida auris made the violation particularly concerning. The organism's resistance to treatment and ability to persist on surfaces for weeks creates ongoing transmission risks. Every breach of protocol potentially extends that risk to other vulnerable residents.
The inspection findings revealed a facility where infection control existed more in policy than practice, where staff education hadn't translated into consistent behavior, and where quality assurance systems failed to catch basic safety violations before federal inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Treasure Isle Care Center from 2024-06-13 including all violations, facility responses, and corrective action plans.