FAR ROCKAWAY, NY - Federal inspectors documented multiple infection prevention violations at Peninsula Nursing and Rehabilitation Center during a July 2024 survey, finding staff failed to follow enhanced safety protocols while caring for residents with central lines and wounds.
Enhanced Barrier Precaution Violations
The facility's own policy required staff to wear gowns and gloves during high-contact care activities for residents with wounds and indwelling medical devices. These enhanced barrier precautions are designed to prevent the transmission of multidrug-resistant organisms - dangerous bacteria that resist standard antibiotics and can cause life-threatening infections in vulnerable nursing home residents.
Despite having clear protocols in place, inspectors observed multiple instances where nursing staff failed to follow these critical safety measures. On June 26, 2024, Registered Nurse #3 was observed performing a dressing change for a peripherally inserted central catheter (PICC line) and administering intravenous antibiotics to a resident. The nurse wore gloves and a mask but failed to wear the required gown, and no signage indicated the resident needed enhanced precautions.
A PICC line is a long, thin tube inserted through a peripheral vein that extends into a central vein near the heart. These devices allow for long-term intravenous treatments but create a direct pathway for bacteria to enter the bloodstream. Without proper barrier precautions, healthcare workers can unknowingly transfer dangerous organisms from their clothing or skin to the catheter site, potentially causing bloodstream infections that carry mortality rates exceeding 25%.
Systemic Communication Breakdown
The inspection revealed concerning gaps in communication and awareness among nursing staff. When interviewed, Registered Nurse #3 stated they "did not know that Enhanced Barrier Precautions were needed" and only learned afterward that the resident had a PICC line requiring special protocols. This knowledge gap represents a fundamental breakdown in the facility's system for communicating critical safety information to frontline caregivers.
Similar failures occurred with other residents requiring enhanced precautions. On June 27, 2024, Registered Nurse #4 was observed performing wound care on a resident with a midline catheter without wearing a gown. The nurse later confirmed there was no enhanced barrier precaution notice posted on the resident's door and stated they "did not know a gown was needed."
Midline catheters, while not extending as deeply as PICC lines, still present significant infection risks. These devices typically remain in place for weeks and require meticulous care to prevent complications. The lack of proper signage and staff awareness creates an environment where infection control protocols become ineffective.
Wound Care Protocol Failures
Inspectors also identified issues with enhanced barrier precautions for residents with serious wounds. One resident with a Stage 3 pressure ulcer measuring 7cm x 8cm was initially placed on enhanced precautions in May 2024, but the order was discontinued later that month despite the wound's continued presence.
Stage 3 pressure ulcers involve full-thickness skin loss extending into subcutaneous tissue. These deep wounds create open pathways for bacterial invasion and require careful infection control measures during treatment. The facility's inconsistent application of enhanced precautions for wound care demonstrates a lack of clear criteria for when these safety measures should be implemented and maintained.
On July 1, 2024, inspectors observed a nurse performing wound care on this resident's sacral pressure ulcer without donning a gown or face mask before entering the room. The nurse later stated they believed the resident was no longer on enhanced precautions because the wound was "healing," despite documentation showing it remained classified as a Stage 3 ulcer.
Hand Hygiene Lapses During Meal Service
Beyond device and wound care issues, inspectors documented hand hygiene failures during meal service - a critical time when proper sanitation prevents foodborne illness transmission among vulnerable residents. On June 27, 2024, a certified nursing assistant was observed distributing hand wipes to residents before lunch but failed to clean their own hands between assisting different residents.
The assistant collected used hand wipes from multiple residents, disposed of them in trash, and wiped their own hands only at the end of the process. When questioned, the staff member acknowledged that "resident's hands may have bacteria" and they "do not want to spread any bacteria to other residents," yet their actions created the exact cross-contamination scenario they sought to prevent.
Proper hand hygiene during meal assistance is particularly crucial in nursing homes, where residents often have compromised immune systems and underlying health conditions that increase their susceptibility to infections. The Centers for Disease Control and Prevention emphasizes that healthcare workers should perform hand hygiene before and after each resident contact to prevent pathogen transmission.
Medical Implications and Industry Standards
The violations documented at Peninsula Nursing Center highlight critical gaps in infection prevention that could have serious consequences for resident health. Healthcare-associated infections represent one of the leading causes of morbidity and mortality in long-term care facilities, with residents facing significantly higher risks than the general population due to advanced age, chronic conditions, and the congregate living environment.
Enhanced barrier precautions serve as a crucial defense against multidrug-resistant organisms, which have become increasingly prevalent in healthcare settings. When these protocols are not followed consistently, facilities create opportunities for dangerous bacteria to spread between residents and staff, potentially leading to outbreaks that can overwhelm a facility's ability to provide safe care.
The Centers for Medicare & Medicaid Services requires nursing homes to maintain comprehensive infection prevention and control programs that include proper use of personal protective equipment, adequate staff training, and clear communication systems. The failures at Peninsula Nursing Center suggest deficiencies in multiple components of their infection control program.
Facility Response and Ongoing Concerns
During interviews, facility leadership acknowledged the importance of enhanced barrier precautions and described processes for determining when these measures should be implemented. The Assistant Director of Nursing explained that residents are assessed for enhanced precautions upon admission and that wound healing progress is regularly evaluated to determine when precautions can be safely discontinued.
However, the disconnect between stated policies and observed practices indicates implementation challenges that extend beyond individual staff errors. The lack of proper signage, inconsistent staff awareness, and varying interpretations of when enhanced precautions are needed suggest systemic issues requiring comprehensive corrective action.
The facility received citations for infection prevention and control violations, with regulators determining the issues posed minimal harm or potential for actual harm to some residents. However, even minimal-level violations in infection control can serve as warning signs of more serious problems if not addressed promptly and thoroughly.
Nursing homes must maintain vigilant infection control practices to protect their vulnerable residents from preventable harm. The violations at Peninsula Nursing Center serve as a reminder of the critical importance of consistent policy implementation, ongoing staff education, and robust quality assurance programs in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peninsula Nursing and Rehabilitation Center from 2024-07-03 including all violations, facility responses, and corrective action plans.
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