Highland Manor: MRSA Patient Shared Room Despite Policy - NV

Highland Manor of Elko Rehabilitation housed Resident #40, who tested positive for MRSA in a leg wound, in the same room as Resident #26, who had chronic kidney disease and diabetes. The contact precautions sign posted outside their shared room warned all staff to wear gowns and gloves before entering, but the facility's own policy stated residents with such infections must be placed in private rooms.

The roommate, Resident #26, told inspectors the precaution sign was meant for Resident #40 because of wounds on that resident's legs. Resident #26 said staff rarely wore protective equipment when providing care.

When confronted about the policy violation, the infection preventionist and assistant director of nursing confirmed Resident #40 was not in a private room as required. The official explained that a wound culture had come back positive for MRSA on June 29, 2024, prompting the contact precautions to prevent the infection from spreading to others.

The facility's own transmission-based precautions policy, revised in January 2024, explicitly stated that residents with infections like MRSA "were to be placed in a private room or placed with a resident with the same infection with the same microorganism." CDC guidelines similarly recommend single rooms for residents requiring contact precautions, noting that healthcare workers should wear gowns and gloves "for all interactions which may involve contact with the resident or potentially contaminated areas."

Resident #40 had been admitted with Parkinson's disease and an unstageable pressure ulcer on the right buttock. The infection preventionist said the resident was initially placed on enhanced barrier precautions, then moved to contact precautions after the MRSA culture results.

The confusion extended beyond room assignments. The infection preventionist struggled to explain the difference between the facility's precaution protocols during the inspection. When asked to compare CDC signage for enhanced barrier precautions versus contact precautions, the official placed the signs side by side and confirmed they had different requirements - enhanced barrier precautions required protective equipment only during "high-contact care activities," while contact precautions required gowns and gloves upon every room entry.

Meanwhile, the facility failed basic vaccination safety protocols for another vulnerable resident. Resident #26, who had stage-four chronic kidney disease and required dialysis, received both influenza and pneumococcal vaccines in May 2023 without being screened for eligibility or contraindications.

The vaccination consent forms for both shots were completely blank in the sections marked "Risk Assessment" and "Assessment for contraindications." Despite signing consent and receiving the vaccines, Resident #26's medical record contained no evidence of safety screening before the injections were administered.

The infection preventionist acknowledged that all residents should be screened for vaccine eligibility "to ensure it was safe to administer the vaccinations." The official confirmed Resident #26 had received both vaccines without the required screening.

For residents with severe kidney disease like Resident #26, certain vaccines may require dose adjustments or timing considerations. The facility's own policies, revised in January 2024, required screening for contraindications before administering either vaccine.

The administrator confirmed the infection preventionist was responsible for both the infection control program and antibiotic stewardship, but acknowledged the facility lacked a formal job description for the infection prevention role. The position was considered part of the assistant director of nursing's duties.

A job description signed by the infection preventionist in June 2023 documented responsibility for monitoring compliance with CDC guidelines for isolation and treatment of infections. The facility's transmission-based precautions policy stated it would "follow nationally recognized standards and guidelines" for preventing infections.

CDC guidance emphasizes that contact precautions are implemented "to contain pathogens" by requiring protective equipment upon room entry and removal before leaving. The agency's 2024 guidance specifically distinguishes contact precautions from enhanced barrier precautions, noting that contact precautions require gowns and gloves "on every entry into a resident's room, regardless of the level of care being provided."

Federal inspectors found these violations during a routine health inspection completed July 18, 2024. Both deficiencies were classified as causing minimal harm or potential for actual harm to residents.

The vaccination screening failure affected one of five residents sampled for immunization compliance. The room-sharing violation involving the MRSA patient was part of broader infection control findings that affected some residents at the 89801 zip code facility.

Resident #26 was readmitted to Highland Manor after an earlier stay, carrying diagnoses that included acute and chronic respiratory failure with low oxygen levels in addition to the kidney disease and diabetes. The resident's compromised immune system from kidney failure and dialysis dependence made proper infection control protocols particularly crucial.

The facility's infection preventionist told inspectors that wound cultures would trigger "more of a contact thing" when determining isolation precautions. But the official's explanation of when staff needed protective equipment conflicted with the posted CDC signage requiring gowns and gloves for all room entries, not just direct patient contact.

Highland Manor of Elko operates at 2850 Ruby Vista Drive in Elko, Nevada. The facility is required to submit a plan of correction addressing both the isolation protocol failures and vaccination screening gaps identified during the federal inspection.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Highland Manor of Elko Rehabilitation LLC from 2024-07-18 including all violations, facility responses, and corrective action plans.

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