Springs at Rochester Hills: Infection Control Failures - MI
The violation occurred during federal inspectors' August visit to The Springs at Rochester Hills Rehab and Nursing Center, where they found the facility's infection control program had collapsed under the weight of corporate transition and understaffing.
The nurse was treating Resident 58, a patient with severe brain injury who depends on a tracheostomy tube for breathing and receives nutrition through a stomach tube. When inspectors observed the trach care on August 27, they watched the nurse lift the patient's foam collar tie to reveal "a large amount of secretions" on the resident's neck.
The nurse opened a sterile trach kit and removed his regular gloves to put on the sterile ones. But he never washed his hands between the glove change. After wiping away the secretions with gauze from the kit, he applied clean gauze under the trach mask using the same contaminated gloves.
The Director of Nursing confirmed the violation when questioned by inspectors. Hand hygiene and fresh gloves should occur "whenever you are going from dirty to clean," she told them. The nurse "should have removed his gloves, performed hand hygiene, and donned clean gloves between cleaning the secretions and applying clean gauze."
The contamination incident reflected broader systemic failures in the facility's infection control program. Inspectors discovered the infection control nurse responsible for preventing disease outbreaks devoted just four hours per week to infection surveillance while juggling roles as staff development coordinator, unit manager, and cart nurse.
The nurse, identified as ICN J, had been hired three months earlier when the facility changed corporate ownership. Missing from the infection control program were monthly analysis reports for May, June, and July 2024, and no surveillance log existed for July.
When inspectors reviewed the July antibiotic audit, they found three residents had been treated with antibiotics for urinary tract infections, but only one appeared on the facility's infection mapping system.
ICN J admitted to inspectors she didn't know what the monthly analysis reports were supposed to contain. When shown an April 2024 report, she said she "had questions regarding the math and determining the infections for the report" and hadn't completed one since taking the job.
The infection control nurse had attended just one quality improvement meeting since her employment began, despite the meetings being scheduled monthly. She blamed the corporate transition for the irregular meeting schedule.
The facility's antibiotic stewardship program showed similar gaps. Inspectors found five residents had received antibiotics without proper documentation of whether their infections met clinical criteria or whether the prescribed drugs were appropriate.
Resident 23 received Cephalexin for arm swelling from a hospital IV site, with notes indicating the antibiotic was started "as prophy" (prophylaxis). The resident was later hospitalized and found to have a gastrointestinal bleed with no infection, but had already received multiple antibiotic doses.
Resident 212 returned from the hospital on Doxycycline for pneumonia, but inspectors found no documentation reviewing the antibiotic's appropriateness in the medical record.
In June, Resident 58 received seven days of Levaquin for an unspecified infection, with surveillance logs noting only "Infection - Other" and no documentation of whether the infection met diagnostic criteria.
Resident 1 received Amoxicillin-Clavulanate for a urinary tract infection, but inspectors found "no documentation of signs/symptoms that met criteria for a uti and no documentation of the appropriateness of the antibiotic."
Most concerning was Resident 11, who received Macrobid for a urinary tract infection in July. The medical record showed a urinalysis had been ordered, but contained no results from the test or culture report to justify the antibiotic treatment.
When asked how she determined if infections met criteria, ICN J told inspectors the facility used McGeer's criteria but relied on a new software system being implemented by the corporation. "Once transitioned," she said, "the software would inform them if it met criteria."
The infection control failures extended to vaccination requirements. Inspectors found two residents, including the brain-injured Resident 58, had never been offered pneumococcal or COVID-19 vaccines despite facility policies requiring education and vaccination offers upon admission.
ICN J told inspectors the facility had "a new process in place under the new ownership that will bundle the education and consents for all immunizations." When asked to provide documentation of vaccine education for the two residents, she returned empty-handed, saying she "was unable to find the requested documentation."
The facility's infection control policy, updated just days before the inspection on August 1, promised "comprehensive" prevention and control addressing "prevention, identification, reporting, investigation and controlling of infections and communicable diseases among residents, employees, volunteers and visitors."
The policy specified "on-going monitoring for infections among residents" and required "infection prevention and control reports are made to the QAA (quality assurance) committee."
But the reality inspectors found was a program run by an overwhelmed nurse working part-time hours on infection control while managing multiple other responsibilities. The corporate transition had disrupted basic surveillance functions, leaving residents vulnerable to preventable infections and inappropriate antibiotic use.
ICN J promised inspectors that both residents would be educated about vaccines "today 8/28/24," the final day of the survey. She offered no timeline for restoring the missing surveillance reports or implementing proper antibiotic oversight.
The violations affected all 62 residents at the facility during the inspection period, exposing them to infection risks from contaminated care procedures and inadequate disease surveillance systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Springs At Rochester Hills Rehab and Nursing C from 2024-08-28 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
The Springs at Rochester Hills Rehab and Nursing C in Rochester Hills, MI was cited for violations during a health inspection on August 28, 2024.
The nurse opened a sterile trach kit and removed his regular gloves to put on the sterile ones.
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.