Almond Vista Healthcare: Infection Control Failures - CA
The infection control breakdown at Almond Vista Healthcare affected vulnerable residents who depended on staff to prevent cross-contamination during intimate medical procedures. Federal inspectors documented the failures during an August 2024 visit to the 161-bed facility on Evergreen Avenue.
Resident 81 had been readmitted with obstructive uropathy and required suprapubic catheter care. Laboratory results from February showed the resident's urinary tract infection included the dangerous Citrobacter bacteria. On August 2, inspectors watched Licensed Vocational Nurse 1 perform the catheter care routine.
The nurse put on gloves and cleaned the catheter site. Without changing gloves, she rinsed and patted the area dry. Only then did she remove the contaminated gloves, wash her hands, and put on fresh gloves to apply the sterile dressing.
"I did not realize that I did not change my gloves when going from dirty to clean," the nurse told inspectors afterward. She confirmed she should have changed gloves between the cleaning and drying steps.
The Director of Nursing and Infection Preventionist both confirmed to inspectors that gloves must be changed when moving from contaminated areas to clean areas during medical procedures. The facility had provided personal protective equipment training to staff in May, just three months before the inspection. Licensed Vocational Nurse 1 had attended the session on proper donning and doffing of protective gear.
A second resident faced different infection risks. Resident 79, who had severe cognitive impairment and required a suprapubic catheter due to neurogenic bladder, was found with his urine collection bag sitting directly on the floor.
The resident had been living at the facility since 2023 with conditions including asthma and benign prostatic hyperplasia. His mental status score of seven out of 15 indicated severe cognitive impairment, making him unable to advocate for proper care.
During the inspection, Licensed Vocational Nurse 2 found the resident lying in bed with linens over his head and his urinary collection bag on the floor beside the bed. The bag lacked a dignity cover. The nurse confirmed the bag should have been elevated off the floor and placed in a dignity bag to reduce infection risk.
"The urinary collection bag was on the floor, should have been in a dignity bag, and off the floor due to risk for infection," the nurse told inspectors.
The Director of Nursing stated it was her expectation that all urinary collection bags be kept off floors and placed in dignity bags specifically to prevent infections. The facility's own catheter care policy, revised in August 2022, explicitly required staff to keep "catheter tubing and drainage bag off the floor" to prevent catheter-associated complications and urinary tract infections.
Beyond direct patient care failures, the facility struggled with basic quality oversight systems. The Quality Assurance and Performance Improvement committee, required to meet quarterly with specific members present, had operated without required attendance for multiple quarters.
The Administrator confirmed that QAPI meetings should include the Administrator, Director of Nursing, Infection Preventionist, and Medical Director. During the third and fourth quarters of 2023, the Medical Director failed to attend. In the first quarter of 2024, neither the Infection Preventionist nor Medical Director participated in the quality oversight meetings.
The facility's QAPI policies, dating from 2014 and 2020, contained no attendance requirements for the mandatory quarterly meetings. This meant the committee charged with identifying and addressing quality issues operated without the medical expertise required by federal regulations.
Administrative failures extended to another area affecting residents' rights and financial obligations. The facility had implemented a Performance Improvement Plan specifically for ensuring residents received proper notification when their beds would be held during hospital stays. These notifications affect whether residents must pay privately to maintain their rooms during medical emergencies.
The Director of Nursing confirmed the bed hold notification plan included conducting regular audits, but she could not provide any completed audits to inspectors. The Assistant Director of Nursing was aware of the improvement plan but had not conducted audits herself, assuming Medical Records staff handled the reviews.
The Medical Records Director, who started conducting bed hold audits in May 2024, confirmed the audits remained incomplete. The Administrator acknowledged he knew the required audits had not been completed according to the facility's own improvement plan.
Resident 79 remained at risk with his catheter bag on the floor, while Resident 81 continued receiving care from staff who had demonstrated they did not follow basic infection control protocols even after recent training. The facility's quality oversight committee continued meeting without the medical professionals required to identify and address such systemic care failures.
The infection control violations affected residents already vulnerable to healthcare-associated infections, including those with compromised immune systems and indwelling medical devices. Citrobacter freundii, the bacteria found in Resident 81's urinary tract, commonly spreads through contaminated hands and equipment in healthcare settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Almond Vista Healthcare from 2024-08-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ALMOND VISTA HEALTHCARE in MODESTO, CA was cited for violations during a health inspection on August 2, 2024.
Federal inspectors documented the failures during an August 2024 visit to the 161-bed facility on Evergreen Avenue.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.