DUBUQUE, IA - Federal inspectors documented serious infection control breaches at Sunnycrest Manor after observing nursing staff fail to follow basic hygiene protocols while treating a resident with an active MRSA infection, creating significant risk for cross-contamination.
Critical Infection Control Violations
The February 2025 inspection revealed that nursing staff failed to implement proper hand washing and wound care procedures when treating a resident with Methicillin-resistant Staphylococcus aureus (MRSA), a dangerous antibiotic-resistant bacteria that can cause life-threatening infections.
Resident #34 had developed a left heel blister that was drained in October 2024 and subsequently tested positive for MRSA. The resident also had cellulitis in the left lower extremity and an open area on the right great toe. Due to the active MRSA infection, the care plan specifically required contact isolation protocols including wearing gowns and gloves, proper hand washing before entering and after exiting the room, and careful handling of contaminated linens.
During the inspection, surveyors observed a Licensed Practical Nurse (LPN) providing wound care to both the infected left heel and the right great toe. The nurse failed to follow critical infection control steps that could have prevented cross-contamination between the wounds and potential spread to other areas of the facility.
Dangerous Protocol Violations Observed
The nurse committed multiple serious breaches of infection control protocol during the wound care procedure. After removing soiled dressings from both wounds, the staff member did not wash hands or change gloves before proceeding with treatment. The nurse then cleansed both wounds with soap and water and dried them without changing gloves or washing hands between treating each wound site.
Even more concerning, the nurse removed outer gloves and put on a new pair, but then treated both wounds again without changing gloves or washing hands between the different wound sites. After completing the treatment, the nurse removed gloves and cleaned up supplies, but then left the room still wearing personal protective equipment.
The nurse proceeded to touch multiple surfaces outside the isolation room, including the medication cart and door handles, before finally washing hands. This sequence of actions could have contaminated common areas and equipment with MRSA bacteria.
Medical Significance of MRSA Cross-Contamination
MRSA infections pose serious health risks, particularly in nursing home environments where residents often have compromised immune systems. The bacteria can cause severe skin and soft tissue infections, pneumonia, bloodstream infections, and in some cases, death. MRSA is resistant to many common antibiotics, making infections difficult to treat once they occur.
Cross-contamination between wounds on the same patient can spread the infection to new body sites and worsen the resident's condition. When proper isolation protocols are not followed, MRSA can spread to other residents through contaminated hands, equipment, or environmental surfaces.
The care plan for Resident #34 specifically outlined contact isolation procedures because of the known MRSA infection, making the protocol violations particularly serious. These precautions are designed to contain the bacteria and prevent its spread throughout the facility.
Industry Standards for Infection Control
Proper wound care protocols require treating each wound site separately to prevent cross-contamination. Standard procedures involve washing hands and changing gloves between treating different wounds, even on the same patient. When dealing with antibiotic-resistant organisms like MRSA, these precautions become even more critical.
Nursing staff interviewed during the inspection demonstrated understanding of correct procedures. One Registered Nurse explained the proper protocol: treating one wound at a time, washing hands and donning clean gloves before moving to the next wound site, and completing hand hygiene before leaving the room without gloves.
The facility's own Hand Washing policy, reviewed in 2024, required hand hygiene before and after changing dressings and identified hand washing as the primary method for preventing infection transmission.
Additional Food Safety Concerns
Beyond the infection control violations, inspectors also cited the facility for ongoing food service safety issues. Despite previous citations, the kitchen continued to have problems with undated open foods, inadequate temperature monitoring of refrigerators and freezers, improper sanitizer chemical levels, dented cans, expired food, and dusty ventilation.
The facility's quality assurance audits showed that in 2024, food was improperly labeled in 13 out of 44 documented cases. However, these audits did not include documentation of staff education provided to address the identified problems.
Administrative Response and Quality Improvement
The facility Administrator acknowledged the QAPI (Quality Assurance and Performance Improvement) committee's awareness of the ongoing kitchen issues and stated they had been working to address the concerns. The committee meets every two months and includes input from residents, family members, and department heads.
The Certified Dietary Manager reported working on implementing a new meal service ticketing system to improve accuracy and budgeting. However, the persistence of food safety violations from previous inspections suggests that corrective measures have not been fully effective.
Implications for Resident Safety
The combination of infection control failures and food safety violations creates a concerning pattern of basic safety protocol breakdowns at Sunnycrest Manor. The MRSA contamination risk is particularly serious given the vulnerable population of nursing home residents who may have weakened immune systems or existing health conditions that make them more susceptible to infections.
Proper infection control is fundamental to nursing home operations, especially when caring for residents with known infectious diseases. The observed violations suggest gaps in staff training, supervision, or compliance monitoring that could affect other aspects of resident care.
The 73-bed facility must implement comprehensive corrective measures to ensure staff consistently follow infection control protocols and maintain food safety standards to protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunnycrest Manor from 2025-02-27 including all violations, facility responses, and corrective action plans.
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