The January inspection at Harrison Nursing and Rehabilitation Center revealed multiple infection control breakdowns that put all 49 residents at risk. Federal inspectors documented nurses skipping safety protocols, cleaning medical equipment with contaminated gloves, and administrators failing to monitor the facility's water system for dangerous bacteria.
Licensed Practical Nurse 3 gathered testing supplies on January 22 and entered the room of Resident 44, a diabetic patient with moderate cognitive impairment who required enhanced barrier precautions due to an infected wound. The nurse performed the blood sugar test without donning the required gown, then placed her contaminated supply tray directly on an unclean surface.
After the procedure, she cleaned the glucometer with a single disinfectant wipe for 24 seconds. The manufacturer's instructions require surfaces to remain visibly wet for two minutes to kill bloodborne pathogens. She then returned the improperly disinfected device to the medication cart without placing a protective barrier underneath the contaminated tray.
"Two minutes," the nurse told inspectors when asked about the required cleaning time. But she could not define what "dwell time" meant and incorrectly believed finger stick tests didn't qualify as high-risk care requiring protective equipment.
The facility's own policy states that enhanced barrier precautions "reduced transmission of multidrug resistant organisms through gown and glove use during high resident care activities." The infection preventionist confirmed that staff must wear gowns and gloves when entering isolation rooms if providing high-contact care, which includes using medical devices.
A second violation occurred the next day when Registered Nurse 1 administered medication to Resident 21, a cognitively intact patient admitted in 2020 with esophageal problems. After providing physical contact and medication, the nurse cleaned her stethoscope with an alcohol wipe while still wearing the gloves she had used during patient care.
"I expected staff to remove dirty gloves, use proper hand hygiene, and re-glove to clean a piece of equipment," Director of Nursing told inspectors.
The Administrator agreed: "Common sense told one to clean equipment with clean gloves."
Beyond individual incidents, the facility failed to implement basic water safety monitoring required to prevent Legionella and other waterborne infections. Federal guidelines require nursing homes to maintain flow diagrams showing their water systems and identify areas where dangerous bacteria could grow and spread.
Harrison Nursing had no such documentation.
The Administrator acknowledged responsibility for water management but admitted she had never completed a Legionella Environmental Assessment Form to identify high-risk areas. She performed quarterly testing using an in-house kit but could not provide documentation of the required control measures, temperature monitoring, or disinfection protocols.
"I did not know about the facility's water management program," the Maintenance Director told inspectors, despite being responsible for checking water temperatures throughout the building.
The infection control failures extended to vaccination documentation. Five residents sampled for immunizations had no record of receiving education about vaccine benefits and side effects, despite facility policy requiring such counseling. Residents with intact cognition confirmed they received no information sheets before vaccination.
"I was not provided a VIS to read or sign prior to administration of my last vaccines," Resident 16 told inspectors. "Education regarding the benefits and risks and potential side effects associated with the vaccine was good information to have to make an informed decision."
Resident 21 said he "did not remember any education about the vaccines" and was simply "asked if he wanted the vaccine."
The facility was using outdated 2023 vaccine information sheets for 2024-2025 vaccines. The Infection Preventionist could not explain why proper education wasn't documented or why current materials weren't available.
Staff vaccination records showed similar gaps. Four employees sampled had no documentation of receiving required COVID-19 vaccine education, despite federal requirements that long-term care facilities offer vaccination and education to all staff.
Licensed Practical Nurse 2 said she received vaccine education but "did not recall if she signed any documentation acknowledging the education or being offered the COVID-19 vaccination." A certified nurse aide similarly remembered receiving education but signing no documentation.
The facility's infection control policy, updated in September 2024, promised annual skill assessments covering protective equipment use, isolation precautions, and safe handling of contaminated equipment. But the Director of Nursing admitted there was "no documentation of staff infection prevention and control audits."
During the inspection, the Director of Nursing was unavailable, unreachable, and out of the facility, leaving the Administrator to explain that quality assurance monitoring was the nursing director's responsibility.
The Medical Director expected the facility to follow all CDC guidelines and policies, with the Director of Nursing and Infection Preventionist overseeing implementation. But the systematic failures suggested a breakdown in oversight at multiple levels.
After inspectors observed the glucometer cleaning violation, Licensed Practical Nurse 3 retrieved the device and cleaned it properly according to facility protocols before using it on another resident. The gesture came too late to prevent potential cross-contamination between patients.
The inspection found residents like 83-year-old Resident 44, admitted in May 2024 with diabetes, chronic lung disease, and an infected foot wound, remained vulnerable to preventable infections due to staff shortcuts and missing safety protocols.
Harrison Nursing's 49 residents depend on staff following basic infection control measures that protect against bloodborne pathogens, multidrug-resistant organisms, and waterborne bacteria like Legionella. The January inspection revealed those protections were inconsistently applied, poorly monitored, and inadequately documented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harrison Nursing and Rehabilitation Center from 2025-01-24 including all violations, facility responses, and corrective action plans.
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