The infection control violations occurred despite facility policies requiring gloves during injections and proper hand hygiene after contact with contaminated surfaces. Administrative staff confirmed they expected nurses to follow these basic safety protocols.
On January 8 at 8:41 a.m., inspectors watched nurse #4 perform hand hygiene but skip gloves entirely while giving Resident #283 two insulin injections. The resident's physician had ordered daily Insulin Glargine 12 units and Novolog 3 units subcutaneous injections.
The facility's own insulin injection policy, dated January 2023, specifically requires nurses to "apply clean gloves" before administering injections. During an interview that afternoon, an administrative staff member confirmed she expected nurses to wear gloves while giving any injection.
A more complex violation occurred during tracheostomy care for Resident #126, who had enhanced barrier precautions and was recovering from a recent Influenza A infection. On January 9 at 11:38 a.m., nurse #5 properly began the procedure by applying a gown and gloves, then performed the sterile portion of the tracheostomy care correctly.
But after completing the sterile care, the nurse removed the sterile gloves, performed hand hygiene, and applied clean gloves for the non-sterile portion. The problems began when nurse #5 removed a used paper napkin from the resident's hands, cleaned the tracheostomy site with cotton swabs and a peroxide-saline solution, and threw the swabs in the garbage.
The nurse then handed the same contaminated paper napkin back to Resident #126. With the same soiled gloves, nurse #5 touched multiple items throughout the resident's room before finally removing the gown and gloves, performing hand hygiene, and leaving.
Two administrative nurses interviewed on January 8 said they expected staff to remove contaminated gloves and perform hand hygiene before moving to other tasks. The facility's hand hygiene policy, updated in October 2024, states that hand hygiene is required "after contact with blood, body fluids or contaminated surfaces" and "after touching the resident's environment." The policy emphasizes that "the use of gloves does not replace hand washing/hygiene."
The inspection also revealed that Woodside Village was addressing a previous safety violation involving wheelchair transport. In September 2024, CNA #8 had transported Resident #87 in a wheelchair without properly positioning the foot pedals, allowing the resident's feet to dangle.
That incident led to a fall on September 7, 2024. The facility completed an investigation on September 13, determining that CNA #8 had provided wheelchair transport without proper foot pedal positioning. The aide was placed on administrative leave on September 10 until further investigation and education was completed.
Following the wheelchair incident, administrators sent email education to all staff on September 10, stating that "foot pedals or leg rests always need to be used when pushing a resident in a wheelchair. It is never acceptable to allow a resident's feet to dangle when pushing them, not even for a short distance."
A September 13 memo reinforced the policy: "ANYTIME a resident is being pushed in their wheelchair the foot pedals MUST BE ON." All nursing staff, including CNA #8, signed rosters indicating they had reviewed and understood the memo. Charge nurses were made responsible for reviewing the education after the September fall.
The facility implemented weekly quality assurance audits to ensure resident safety during wheelchair transport.
But the infection control violations discovered during the January inspection showed ongoing safety lapses. Federal inspectors classified the infection control deficiency as having potential for actual harm, noting that failure to follow proper glove use and hand hygiene standards "has the potential to spread infection throughout the facility."
The violations affected residents with complex medical needs. Resident #126 required tracheostomy care and had enhanced barrier precautions due to a recent Influenza A infection. Resident #283 needed daily insulin injections for diabetes management.
Inspectors found the facility failed to follow infection prevention and control standards for both residents observed during the January 8-9 investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodside Village from 2025-01-08 including all violations, facility responses, and corrective action plans.
