The resident's room displayed a clear sign directing staff to put on gloves and gown before entering and to clean hands before entering and leaving. Instead, the therapy assistant helped the resident walk, removed her gait belt, assisted her into a recliner, picked up water pitchers, walked to the common area to fill them, and returned to the room — all without gloves, gown, or hand sanitization.
When questioned, the therapy assistant said another therapist told her protective equipment was only needed "if they were performing cares."
The director of nursing told inspectors that therapy was considered providing cares and that without proper protective equipment, "C-diff can spread very easily throughout the facility."
Clostridium difficile causes severe diarrhea and colitis, spreads through spores that survive on surfaces, and can trigger life-threatening complications in vulnerable populations like nursing home residents.
The facility's own infection preventionist acknowledged the contact isolation sign should have been replaced with an enteric precautions sign requiring all staff to wear gowns and gloves and wash hands with soap and water, noting that hand sanitizer "was not enough" for C. diff.
Multiple Infection Control Breakdowns
During morning care for another resident requiring enhanced barrier precautions, nursing assistant NA-F entered the room, performed hand hygiene, and put on gloves. The assistant then emptied a urinal half-filled with urine, placed it on the floor, and without changing gloves or washing hands, handled a transfer belt, bed controls, the resident's boots, and compression socks.
NA-F assisted the resident to the bathroom, removed a urine-soiled brief, and provided personal cleaning. Without removing gloves or performing hand hygiene between tasks, the assistant put on a clean brief, helped dress the resident, handled dentures, and assisted with face washing.
The assistant acknowledged not changing gloves after emptying the urinal and not performing hand hygiene after glove removal, explaining the shirt being worn had no pockets for hand sanitizer.
The facility's handwashing policy required hand hygiene after changing incontinent products, after glove removal, and before putting on new gloves. The enhanced barrier precautions policy required protective equipment during "high contact resident care activities such as dressing, transferring and hygiene."
Fall Prevention Mat Left on Floor
Inspectors found a fall prevention mat on the floor of a high-fall-risk resident's room while the resident was in the dining room. The licensed practical nurse said the mat stayed on the floor because the resident "tries to get in and out of bed constantly" and was "at a very high risk for falling."
But a nursing assistant said the mat was "supposed to be on the floor at all times" and verified it should be moved when the resident was in her wheelchair. The assistant noted the resident couldn't figure out how to unlock her wheelchair and would think it was stuck.
The director of nursing said she would talk with aides about why the mat was on the floor and noted housekeeping lacked access to care plans. A nursing assistant's daily report sheet failed to include fall prevention interventions or whether the mat should be removed when the resident was in her chair.
Residents Unaware of Menu Options
Two residents told inspectors they never received menus and didn't know alternative food options existed.
R14, who has diabetes and requires a consistent carbohydrate diet, said he "never knows what he's going to get to eat for each meal" and hadn't received a menu. Staff didn't ask what he wanted before meals, he said, adding "I just have to eat what they give me."
When shown the weekly menu and alternate "Bistro" menu during a follow-up interview, R14 said he'd never been given a menu until a week earlier and had to ask for it. He'd never seen the alternate menu and didn't know those choices existed.
R98, admitted with C. diff, sepsis, and urinary tract infection, said she "didn't know what she was going to get to eat each meal until it showed up in her room." She hadn't received a menu and was unaware of alternative options, eating items she disliked, including green beans "with all kinds of other stuff in them."
The cook said residents knew the menu from postings in dining halls and could ask for one, but staff didn't go to rooms asking meal preferences. "The resident's don't get two choices. It's more of a fixed menu."
The dietary manager confirmed they used a five-week fixed menu with typically one option unless serving fish or pork. The Bistro alternate menu wasn't distributed to residents or posted but kept in a hanging file by the kitchen.
Nursing staff gave conflicting information about menu distribution. One registered nurse said nursing assistants were responsible for distributing menus "but anyone can do it." A licensed practical nurse said they provided menus to conscious residents but didn't distribute the alternate menu because "if the resident wants something different they will ask for it."
The facility's menu policy required copies posted "in at least two resident areas, in positions and in print large enough for residents to read them."
Missing Staffing Information
Daily staffing postings lacked required information from July 26 through August 6. The administrator verified the census number was missing from the August 6 posting and wrote it in when asked. Forms also failed to include total hours worked by registered nurses, licensed practical nurses, and nursing assistants.
The director of nursing acknowledged the postings lacked tallied hours and said she corrected the August 7 posting to include required totals going forward.
Federal regulations require facilities to post complete nurse staffing information daily, including the number and actual hours worked by each category of nursing staff and the current resident census.
The facility operates 48 beds and houses residents with complex medical conditions including diabetes, heart disease, Parkinson's disease, and infections requiring isolation precautions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Estates At Greeley LLC from 2024-08-07 including all violations, facility responses, and corrective action plans.