The aide told inspectors she didn't see the sign and didn't know the resident was on special infection control protocols. She acknowledged she should have worn an isolation gown while providing direct care to prevent the spread of infection.
Federal inspectors documented widespread infection control failures at Colonial Care Center during a February 2025 survey, finding staff repeatedly ignored protective equipment requirements for residents with feeding tubes, catheters, and open wounds. The violations affected residents across the 37-person sample reviewed.
The facility wrapped bed rails in black foam and paper tape that couldn't be properly disinfected. Staff touched catheters without gloves. Required warning signs were missing from rooms. The infection prevention nurse admitted the facility had no tracking system for staff COVID-19 vaccinations despite written policies requiring documentation.
Missing Protections for Vulnerable Residents
Resident 19, a quadriplegic with chronic lung disease, was readmitted to Colonial Care Center in May 2023 after initially living there for nearly 20 years. A December 2024 physician's order placed the resident on enhanced barrier precautions due to the tracheostomy tube.
When inspectors observed the resident's care on February 4, both shoulders were elevated on pillows, elbows bent, neck and upper body hunched forward. The restorative nursing aide stood beside the bed wearing gloves but no isolation gown while completing passive range of motion exercises on the left arm.
The aide picked up the resident's right arm and provided exercises to the shoulder, elbow, wrist and hand. After finishing, she removed both gloves, washed her hands, and left the room.
"I did not know Resident 19 was on EBP precautions," the aide told inspectors 13 minutes later. "I did not see a sign indicating Resident 19 was on EBP precaution upon entrance to Resident 19's room and did not see the sign posted on the wall behind Resident 19's bed."
The infection prevention nurse explained that enhanced barrier precautions require gowns and gloves during high-contact activities like range of motion exercises for residents with tracheostomies, feeding tubes, catheters and open wounds. The Director of Nursing said proper infection control protocols prevent spread and cross contamination.
Facility policy, revised in June 2024, specifically requires gowns and gloves during high-contact resident care activities for enhanced barrier precautions.
Bed Rails Wrapped in Materials That Couldn't Be Cleaned
Resident 87, admitted with epilepsy and brain dysfunction, had bilateral padded side rails on his bed wrapped in black foam and white paper tape. The resident was rarely or never understood, according to assessment records, and had a December 2024 order for the low bed with padded rails to decrease potential injury.
The infection prevention nurse told inspectors the facility used two different disinfectant cleaners on surfaces. Both product labels specified they worked only on hard, non-porous surfaces.
"The foam and tape wrapped on the bedrails was not appropriate because they were porous and could cause the surface to not be cleaned properly and also break down the foam and tape," the infection prevention nurse said.
The Diversey Oxivir 1 Disinfectant Cleaner used in the subacute unit where Resident 87 lived was labeled as effective only on "hard, nonporous inanimate surfaces." The Diversey Virex Plus cleaner used elsewhere carried identical restrictions.
Missing Warning Signs and Improper Equipment Use
Resident 343, who lacked capacity to make decisions due to severely impaired cognitive skills, had a feeding tube, urinary catheter, and nephrostomy bag draining urine from the kidney. A January 29 physician's order required enhanced barrier precautions related to the feeding tube.
When inspectors checked the room on February 3, no enhanced barrier precaution signage appeared above the bed or outside the door.
"Resident 343 is supposed to have a EBP signage and does not have one," the infection prevention nurse confirmed during a February 5 observation.
During that same visit, a certified nursing assistant entered Resident 343's room without protective equipment, lifted the blanket covering the urinary catheter, and reached inside the privacy bag to expose the collection bag. The assistant told inspectors she would normally wear a gown for precautions and infections, and that not wearing protective equipment could transmit infection to other residents.
"Even with or without a precautionary sign on the wall, they are trained to wear PPE if they have a resident with a g-tube," the assistant said. She acknowledged she didn't wear gloves this time because inspectors had requested to see the catheter.
After touching the catheter bag, the assistant touched her mask with the same hand without performing hand hygiene.
A registered nurse caring for Resident 16, who had a feeding tube and enhanced barrier precaution sign posted above the bed, lifted the resident's blanket to show the tube location without wearing a gown. The nurse said she would wear protective equipment during direct patient care but considered it unnecessary otherwise.
Facility policy requires gowns and gloves during device care involving feeding tubes and urinary catheters, regardless of whether it constitutes "direct patient care."
Antibiotic Oversight Failures
The facility's infection prevention nurse failed to notify physicians when residents received antibiotics that didn't meet established medical criteria. Two residents completed full courses of antibiotics despite infection screening evaluations that showed "No IPC Case Triggered."
Resident 154, who had respiratory failure and required a tracheostomy and feeding tube, received five days of ceftriaxone injections for a urinary tract infection. Resident 29, diagnosed with dementia and high blood pressure, completed seven days of oral cephalexin for a "possible UTI."
"Resident 154's symptoms did not meet criteria, and there is no documentation indicating the physician was notified," the infection prevention nurse told inspectors. The same applied to Resident 29.
The Director of Nursing said physicians must be notified when residents don't meet antibiotic criteria. The infection prevention nurse's job description requires reviewing every antibiotic order to ensure proper indication and sharing feedback with physicians.
Training and Documentation Gaps
The facility provided no effective communication training to direct care staff in 2024, despite written policies requiring it. The Director of Staff Development said she was unaware the training was mandatory for the facility's 18 registered nurses, 50 licensed vocational nurses, and 20 respiratory therapists.
"Without this training, staff may lack the necessary skills to communicate properly with residents," the staff development director acknowledged.
The Director of Nursing said effective communication training was essential for non-English speaking residents and those with dementia, brain injuries, or strokes who require specialized communication methods.
Similarly, no quality assurance and performance improvement training was provided to direct care staff, despite facility policies requiring it. The staff development director admitted she didn't know the training was mandatory and couldn't explain the potential outcomes of not providing it.
The infection prevention nurse told inspectors the facility maintained no tracking log or records of staff COVID-19 vaccination education, proof of vaccination, or declinations. This violated the facility's August 2024 COVID-19 policy requiring documentation of staff vaccinations and written declinations from those refusing.
The administrator acknowledged during the February 6 interview that CPR and weight loss issues "were not identified prior to the recertification survey" and "should have been caught via training and follow through, but they were not."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Colonial Care Center from 2025-02-06 including all violations, facility responses, and corrective action plans.