Federal inspectors declared immediate jeopardy at Focused Care at Beechnut after finding the catheter trauma to Resident 72, a stroke patient with moderate cognitive impairment who requires a catheter due to neurogenic bladder dysfunction.
The resident told inspectors on June 27 that his catheter was "pulling and rubbing on his skin" and "it was very painful and he had a slit now."
Inspectors observed nursing assistant CNA B providing catheter and incontinence care to Resident 72 that morning. She never washed her hands before putting on gloves. When she cleaned the catheter twice with wet wipes, inspectors saw the resident's penis was "slit from the base to the scrotum and was red and raw."
The resident had soiled himself with a moderate amount of feces. CNA B cleaned the bowel movement, folding the wipes in half twice after each use. Using the same contaminated gloves, she then picked up a clean brief and placed it on the resident without changing gloves or sanitizing her hands. She also failed to secure the catheter properly.
Medical assistant MA D, who helped with the transfer, told inspectors afterward that "CNA did a good job only she did not change gloves and she used the same gloves throughout the procedure. She was supposed to change gloves from soiled to dirty or use hand sanitizer."
When confronted, CNA B admitted she "forgot to wash her hands and change gloves." She had worked at the facility for one year and said she knew to report resident pain complaints to the charge nurse, though the resident had not complained before.
The director of nursing told inspectors that not washing hands, not changing gloves, and not sanitizing between glove changes "could result to cross contamination and infection."
Resident 72's medical records showed he was readmitted to the facility in 2024 with diagnoses including stroke effects, kidney disease, depression, and neurogenic bladder. His care plan from January 2021 noted he was at risk for urinary tract infections due to his bladder dysfunction and required checking catheter tubing for kinks each shift.
A physician's order from June 2024 authorized changing his catheter as needed for dislodgement or blockage issues.
The facility's systemic failures extended beyond individual staff mistakes. Administrators discovered their follow-up system for specialist appointments had completely broken down.
Another catheter patient, Resident 74, had visited a urologist on June 20, but the doctor's paperwork never made it back to the facility. The administrator and director of nursing, both new to their positions, told inspectors they were unaware the follow-up system wasn't working.
"The DON said if a resident missed an appointment, it could have caused a delay in care," inspectors wrote. "She also found out that nurses were calling the Urologist's office but not documenting it."
The social worker, who previously handled specialist appointments, said nursing staff would now assist with paperwork and documentation. The new system requires sending residents to appointments with envelopes for return documentation and having charge nurses contact offices if materials don't come back.
Inspectors found the facility's infection control problems extended beyond individual patient care. In the laundry room, staff had placed personal food items directly on the table used for folding clean linens. Two white cups with sauce, a bowl of fruit, a plastic spoon, and a black comb sat touching folded linen.
Clean items littered the floor throughout the laundry area. One leg boot, four socks, two blankets, and three pillowcases lay on the floor under clean racks. Clean clothes were stored in the dirty section of the laundry room, with an orange sweatshirt and shirt on the floor under a rack.
The hand-washing soap dispenser in the dirty section had been broken for weeks. Laundry aide LS A told inspectors she had been walking to the visitor's restroom in the hallway to wash her hands, creating additional contamination risks.
"It was an infection control issue when staff placed their items on the clean folding table where clean linens were placed because the germs from the staff items could be transferred to the resident," LS A said. "The resident could get sick because the linens may have been contaminated with germs from the staff's personal items."
Director of housekeeping DHK confirmed the soap dispenser had been broken since he started working on May 20. He acknowledged that staff personal items on the folding table created infection control issues and that storing clean clothes on floors contaminated them with germs.
The administrator, observing the broken soap dispenser with inspectors, said the laundry aide's trips to the hallway restroom created contamination risks. "She could have contaminated her hands on her way back to the clean area in the laundry room and could have transferred the germs to the clean linens," he said.
Food safety violations compounded the facility's infection control failures. Inspectors found expired cottage cheese in the walk-in cooler and containers of shredded cheese and sliced American cheese with no opening dates or use-by dates.
A container of frozen fish fillets sat submerged in 71.8-degree water in the kitchen sink, with the fish temperature at 66.4 degrees Fahrenheit, well within the danger zone for bacterial growth. Food service manager acknowledged that proper thawing required running water at 70 degrees or below and fish temperatures of 41 degrees or lower.
Inspectors also found a scoop left in the ice maker bin, violating food safety protocols.
Outside the kitchen, both commercial dumpsters sat three-quarters full with their doors wide open. The food service manager confirmed that dumpster doors "must always be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility."
The facility implemented immediate corrective actions after inspectors declared the immediate jeopardy. They completed head-to-toe assessments on all residents with catheters, provided one-on-one training to the treatment nurse, and conducted facility-wide in-services on catheter care and infection control.
By June 30, inspectors confirmed the immediate jeopardy had been removed after interviewing multiple staff members who demonstrated proper knowledge of catheter care and infection control procedures.
But Resident 72's ordeal highlighted the human cost of the facility's systemic failures. When inspectors spoke with him on June 30, he said he was feeling okay but "wondered why it took the facility so long to address his catheter." He expressed new fears about developing an infection from his feeding tube stoma, though staff confirmed the white substance he worried about was therapeutic cream, not infection.
The facility remained out of compliance at the time inspectors completed their survey, requiring ongoing monitoring to ensure the effectiveness of their corrective systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care At Beechnut from 2024-07-02 including all violations, facility responses, and corrective action plans.
