Resident 58, admitted to Stanford Court Skilled Nursing & Rehab Center with malignant neoplasm of endometrium, required neutropenic precautions due to her compromised immune system. Her door displayed signage indicating the special infection control measures.
But on July 30, state inspectors found her roommate's bedside table held a basket of raw fruits. The roommate, Resident 59, told inspectors her daughter had brought the basket "few weeks ago" and left it on the table.
"I did not realize the raw fruits were not allowed in the room," Resident 59 said.
A supervisor removed the fruit only after state inspectors spotted it during their visit.
The facility's own policy, dating to April 2018, explicitly prohibits raw fruits and vegetables in neutropenic rooms. Resident 58's admission orders from September 2023 specified "no outside food, plants, and flowers" as part of her neutropenic precautions.
Staff knew the rules but failed to enforce them consistently.
Certified Nursing Assistant 23 explained that Resident 58 was "prone to infection" and required protection "from outside germs brought in by staff and visitors." The aide said staff must wear gowns and practice hand hygiene before entering the room.
But the same aide said fruits and vegetables were allowed "if they have been washed" — contradicting the facility's written policy that prohibits all raw produce.
Licensed Nurse 22 correctly stated the policy: "There should be no fresh or raw fruits, vegetables, or flowers in Resident 58's room."
Yet the prohibited items sat openly for weeks.
The Director of Nursing acknowledged learning about the fruit on July 30 and personally removing it from Resident 59's bedside table. She emphasized that "staff should be following the neutropenic protocol to protect Resident 58 from contamination and infection."
"It was important for staff to know what kind of precautions Resident 58 required," the director said.
Cancer patients undergoing treatment often develop neutropenia, a condition where white blood cell counts drop dangerously low. The facility monitored Resident 58's white blood cell levels through laboratory work, according to Licensed Nurse 21.
Neutropenic precautions exist because even common bacteria and fungi that pose no threat to healthy people can cause life-threatening infections in immunocompromised patients. Raw fruits and vegetables harbor microorganisms that proper cooking would eliminate.
The Infection Preventionist Nurse described Resident 58 as "bedbound but goes outside of her room at times with a mask to protect herself from infection from all sources."
Staff described inconsistent visitor compliance with safety protocols. CNA 23 noted that visitors "must gown up too but often they did not."
The facility's policy requires family members and visitors to wash hands, wear gowns, and put on masks when entering neutropenic rooms. Licensed Nurse 22 said visitors were "advised to gown up and are not allowed to bring fruits, vegetables, and flowers of any kind."
But the roommate's daughter had brought and left exactly the items the policy prohibits.
The infection control breakdown extended beyond the fruit basket. Staff gave conflicting information about what items were permitted, suggesting confusion about basic safety protocols for vulnerable patients.
While some staff correctly identified the complete prohibition on raw produce, others believed washed fruits were acceptable — a misunderstanding that could prove dangerous for immunocompromised residents.
Licensed Nurse 21 said staff needed to wear "mask, gown and gloves when entering Resident 58's room." Licensed Nurse 22 similarly described the gowning and masking requirements.
The facility's April 2018 neutropenic precautions policy clearly states that "plants and flowers shall be removed from the resident room" and that "raw and partially cooked meat, vegetables and fruits are prohibited."
Resident 58's September 2023 admission orders reinforced these restrictions with the notation for "neutropenic precautions related to malignant neoplasm of endometrium" specifying no outside food, plants, or flowers.
Despite clear written policies and admission orders, the prohibited fruit remained in the shared room for weeks until state inspectors discovered it.
The Director of Nursing's acknowledgment that she personally removed the fruit only after inspectors found it raises questions about routine monitoring of neutropenic rooms.
For Resident 58, fighting cancer while requiring skilled nursing care, the exposure represented a preventable risk during a vulnerable period when her immune system needed maximum protection from environmental threats.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stanford Court Skilled Nursing & Rehab Center from 2024-08-02 including all violations, facility responses, and corrective action plans.
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