LACEY, WA - Federal inspectors documented widespread infection control failures at Roo-lan Healthcare Center during a February 2025 survey, finding staff repeatedly failed to follow basic hygiene protocols, improperly managed disease outbreaks, and inconsistently implemented protective measures designed to prevent the spread of dangerous infections.
Systemic Hand Hygiene Failures Across All Units
Inspectors observed infection control violations across all four residential halls during the February 6, 2025 inspection, with staff members consistently failing to perform hand hygiene between resident contacts—a fundamental practice for preventing disease transmission in healthcare settings.
On Hall A during the lunch service, a certified nursing assistant delivered meal trays to multiple residents without washing hands or using sanitizer between rooms. The staff member assisted one resident with positioning and moved furniture, then immediately proceeded to another room to handle bedding and bed controls, and then poured beverages—all without a single instance of hand hygiene. In one particularly concerning observation, two nursing assistants entered a resident's room and physically repositioned the person in bed, touching bedding and privacy curtains, then left without sanitizing their hands.
Similar patterns emerged on Hall B, where staff touched privacy curtains, delivered food trays, and moved between resident rooms without hand hygiene. On Hall C, a nursing assistant was observed helping residents in multiple rooms and handling beverage containers in the hallway without cleaning hands between contacts. Hall D observations showed staff picking up items from floors, handling partially consumed drinks, touching furniture, and assisting residents with eating—all without performing hand hygiene between these activities.
Hand hygiene represents the single most effective measure for preventing healthcare-associated infections. Each missed opportunity creates a potential transmission pathway for bacteria, viruses, and other pathogens between residents, staff, and environmental surfaces. In congregate living settings like nursing homes, where residents often have compromised immune systems and multiple chronic conditions, these failures significantly increase infection risk.
The facility's Infection Preventionist acknowledged during interviews that staff were expected to perform hand hygiene during meal service and between resident contacts, stating the observed practices "did not meet expectations."
Confusion and Non-Compliance with Enhanced Barrier Precautions
Inspectors found widespread confusion among staff regarding Enhanced Barrier Precautions (EBP)—specialized infection control measures required for residents with wounds or indwelling medical devices like catheters and feeding tubes. The facility used an orange sticker system to identify residents requiring these precautions, but staff demonstrated limited understanding of what the stickers meant or what protective equipment was required.
Multiple staff members interviewed could not explain the orange sticker system. When a certified nursing assistant on Hall A was asked what an orange sticker indicated, the staff member responded, "I am not sure." Another nursing assistant incorrectly stated the orange sticker meant a resident required thickened liquids. A contracted phlebotomy technician who drew blood from a resident with an EBP designation said isolation precautions "were not explained" and without visible signage, they would not know what protective measures were needed.
The facility's policy requires clear signage outside resident rooms indicating the type of precautions, required personal protective equipment, and specific care activities requiring gown and glove use. However, the facility relied solely on small orange stickers with no explanatory information—a system the Infection Preventionist later acknowledged "did not meet the facility's policy standards."
Enhanced Barrier Precautions exist because residents with open wounds or devices that penetrate the skin face elevated risk for acquiring multidrug-resistant organisms. These pathogens can colonize wounds and device sites, leading to serious infections that are difficult to treat. When staff fail to use appropriate barriers during high-contact care activities like dressing, bathing, or providing hygiene care, they can inadvertently transfer these dangerous organisms between residents.
Even when staff knew precautions were required, compliance was inconsistent. Inspectors observed multiple instances of nurses performing wound care, changing catheter drainage bags, and administering medications through feeding tubes without wearing the required gowns. In one case, a nurse performing wound care for a resident with Stage 2 and Stage 4 pressure ulcers, an indwelling catheter, and a documented multidrug-resistant organism wore only gloves—no gown—despite the resident's EBP status.
Delayed Response to Gastrointestinal Outbreak
The facility's handling of a gastrointestinal outbreak involving both staff and residents revealed significant gaps in outbreak surveillance and response protocols. Staff members first reported vomiting and diarrhea symptoms on January 9, 2025, with residents developing symptoms beginning January 13. The majority of affected residents were located on Hall D, though cases later spread to Hall C.
Despite clear facility policy requiring symptomatic residents to be "assessed for immediate needs" and "placed on empiric precautions while awaiting physician orders," inspectors found multiple residents with active symptoms who had no transmission-based precaution signage outside their rooms and received no isolation measures.
One resident on Hall C told inspectors on January 22, "I have the flu," and reported not feeling well. A certified nursing assistant confirmed the resident had been saying they were sick and had no appetite. The following day, the resident reported throwing up and experiencing body aches and severe headaches. Despite a nurse documenting the resident had vomited, no precautions were implemented. The resident was observed without a mask in hallways and the dining room with other residents present—even after reporting multiple vomiting episodes over several days.
Another Hall C resident reported vomiting twice in one day, four times the previous day, and having diarrhea for three days. The resident stated, "I assumed it was a flu because I was told it was going around." Despite these classic gastrointestinal illness symptoms during a known outbreak period, no precaution signage was posted outside the room. A certified nursing assistant confirmed the resident had been "vomiting continuously" during the previous shift but said they would not wear a gown because the resident didn't have a fever—even though the resident had received fever-reducing medication that could mask elevated temperature.
A third resident on Hall C began vomiting after lunch on February 3. A nursing assistant entered the room wearing mask and gloves but no gown or face shield—despite vomiting presenting a splash risk. The licensed practical nurse on duty said she would check with the Infection Preventionist about implementing precautions. Later that day, the nurse explained she had been told not to post precaution signs until the resident's roommate developed symptoms, because the resident had a history of nausea and vomiting.
Gastrointestinal outbreaks in nursing homes can spread rapidly through person-to-person contact, contaminated surfaces, and aerosolized particles from vomiting. Norovirus, a common cause of such outbreaks, is highly contagious and can survive on surfaces for days. Prompt isolation of symptomatic individuals, implementation of contact and droplet precautions, and enhanced environmental cleaning are critical for containing spread. Delays in implementing these measures allow continued transmission to vulnerable residents and staff.
Medical Context: Why These Violations Matter
Infection control failures in long-term care facilities carry particularly serious consequences because nursing home residents typically face multiple risk factors that increase susceptibility to infection and complicate recovery. Many residents have weakened immune systems due to advanced age, chronic diseases like diabetes and heart disease, malnutrition, and medications that suppress immune function. Residents with wounds, pressure ulcers, and indwelling medical devices have compromised skin and mucosal barriers that normally protect against pathogen entry.
Healthcare-associated infections can lead to sepsis, pneumonia, urinary tract infections, surgical site infections, and bloodstream infections. These complications frequently require hospitalization, intravenous antibiotics, and extended recovery periods. For frail elderly residents, infections often trigger functional decline, increased confusion, falls, pressure ulcer development, and decreased quality of life. Mortality rates for serious infections in nursing home populations remain substantially elevated compared to community-dwelling older adults.
Multidrug-resistant organisms pose an escalating threat in healthcare settings. When staff fail to implement Enhanced Barrier Precautions consistently, these dangerous pathogens can spread from colonized residents to others, establishing new reservoirs within the facility. Once established, MDROs are extremely difficult to eradicate and limit treatment options when infections occur.
Industry standards established by the Centers for Disease Control and Prevention and required by federal regulations emphasize that preventing healthcare-associated infections requires consistent adherence to evidence-based protocols. Standard precautions—including hand hygiene before and after every resident contact—form the foundation. When specific risks are present, such as open wounds, medical devices, or communicable diseases, additional transmission-based precautions create extra protective layers.
Additional Issues Identified
Beyond the major infection control violations, inspectors documented numerous other concerns:
Cross-contamination during wound care: A nurse was observed touching clean wound care supplies and the resident's bedside table with contaminated gloves after handling soiled wound dressings and incontinent care pads, then changing gloves without hand hygiene before continuing the procedure.
Missing residents from antibiotic monitoring: The facility's Antibiotic Stewardship Program failed to include residents on long-term antibiotic therapy in routine monitoring systems designed to track appropriate use and identify potential complications or resistance development. When asked about a resident who had been taking antibiotics since October 2023 but was absent from October, November, and December 2024 tracking lists, the Infection Preventionist said she "did not track indefinite antibiotics." The Director of Nursing Services stated residents on long-term antibiotics should be reviewed regularly and included in monitoring systems.
Inconsistent precaution signage: The facility policy requires specific signage indicating precaution types, required protective equipment, and high-contact activities requiring barriers. The orange sticker system provided none of this information, leaving staff, contracted workers, and visitors without clear guidance.
The facility's Director of Nursing Services, when informed of the multiple infection control failures documented during the survey, acknowledged that staff performance "did not meet expectations" and that residents on long-term antibiotics should be "included on the Antibiotic Line Listing" for ongoing monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roo-lan Healthcare Center from 2025-02-06 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.