SIOUX FALLS, SD - Avantara Norton nursing home faced significant citations from federal inspectors who documented widespread infection control failures affecting multiple residents, including improper hand hygiene during wound care and delayed implementation of enhanced barrier precautions for residents with catheters and wounds.
Critical Hand Hygiene Failures During Wound Care
Federal inspectors observed serious breaches of infection control protocols during wound care procedures involving two residents. During a dressing change for a resident with an abdominal wound, a certified nurse practitioner performed wound debridement, removed contaminated gloves, but failed to perform hand hygiene before putting on new gloves. The licensed practical nurse assisting touched the resident's blanket with gloved hands, then used those same contaminated gloves to open sterile supplies and apply medication to the wound.
In a separate incident involving a resident with leg wounds, the nurse practitioner again demonstrated poor hand hygiene practices. After removing soiled dressings, he changed gloves without performing hand hygiene, then proceeded to touch his iPad screen, reach into his pocket for surgical instruments, and handle photography equipment with contaminated gloves. When reminded by staff that the resident required enhanced barrier precautions due to open wounds, the practitioner applied a gown but continued using the same contaminated gloves for subsequent wound care procedures.
Hand hygiene represents the single most important measure for preventing healthcare-associated infections. When healthcare workers fail to properly sanitize their hands between procedures, they can transfer dangerous bacteria and other pathogens from contaminated surfaces to open wounds, significantly increasing infection risk. Proper protocol requires hand hygiene before and after all patient contact, before putting on gloves, and immediately after removing them.
Delayed Enhanced Barrier Precautions Implementation
The inspection revealed systematic delays in implementing enhanced barrier precautions (EBP) for residents requiring additional infection control measures. Four residents with conditions warranting EBP - including those with urinary catheters and open wounds - experienced delays ranging from four to 114 days before proper signage and protective equipment were placed outside their rooms.
One resident admitted with wounds requiring weekly dressing changes waited 114 days before EBP signage appeared on his door. Another resident admitted with a urinary catheter due to an enlarged prostate experienced a five-day delay before staff implemented proper precautions. A female resident with a post-surgical catheter waited seven days for EBP implementation.
"Staff told her they had to wear a gown now because of her urinary catheter," the resident explained to inspectors, noting the precautions had only begun the previous day.
Enhanced barrier precautions serve as a critical defense against multi-drug-resistant organisms in nursing home settings. These measures require healthcare workers to wear gowns and gloves during high-contact care activities for residents with indwelling devices like catheters or open wounds. Urinary catheters pose particular infection risks, as they provide a direct pathway for bacteria to enter the urinary tract. Without proper barrier precautions, staff can inadvertently spread resistant bacteria between residents during routine care.
Contaminated Personal Care Items and Storage Violations
Inspectors documented extensive problems with unlabeled and improperly stored personal care items throughout the facility. In shared rooms, residents' toothbrushes, razors, deodorant, syringes, and other personal items lacked proper identification, creating significant cross-contamination risks.
One shared bathroom contained three unmarked syringes, unlabeled wound cleanser, two toothbrush containers without resident identification, unmarked deodorant, and a razor with no identifying information. Under the sink, investigators found an unlabeled bedpan stored directly on the floor without proper containment.
Another room revealed similar violations, including an expired catheter insertion tray, unmarked mouthwash bottles, unidentified irrigation syringes, and various personal care items stored without proper labeling or contamination barriers. Medical supplies intended for sterile procedures were stored alongside personal items, increasing contamination risks.
Proper labeling and storage of personal care items prevents cross-contamination between residents and ensures items remain sanitary until use. When multiple residents share bathrooms and personal items lack identification, staff may inadvertently use one resident's contaminated items on another, potentially spreading infections including antibiotic-resistant bacteria, viruses, and other pathogens.
Urinal Management and Sanitation Issues
The inspection revealed serious problems with urinal management affecting multiple residents. One cognitively intact resident had three full urinals containing urine stored above his bed headboard for extended periods, creating strong odors and unsanitary conditions. The resident reported to inspectors that "staff did not empty or rinse his urinals unless he put the call light on and asked them to" and that "he would empty and rinse the urinals when staff would not."
Another resident's catheter drainage bag contained over 2000cc of urine and was described as "bulging" due to lack of regular emptying. The drainage spigot rested on the floor rather than being properly contained, creating additional contamination risks.
Facility policy required urinal emptying once per shift or as needed, with weekly replacement schedules. However, inspectors observed that these protocols were not consistently followed, leaving residents in unsanitary conditions and forcing some to manage their own waste disposal.
Additional Issues Identified
The inspection documented several other infection control violations:
- COVID-19 Precaution Errors: A resident with confirmed COVID-19 was initially placed on droplet precautions rather than the CDC-recommended airborne precautions, though the facility's policy acknowledged they lacked proper airborne isolation rooms
- Medication Storage Violations: Catheter care supplies were improperly stored in resident rooms rather than designated sterile supply areas
- Environmental Contamination: Musty urine odors throughout facility hallways, contaminated gloves on bathroom floors, and medical equipment stored in unsanitary conditions
- Staff Training Gaps: Nursing assistants demonstrated incomplete understanding of when to implement enhanced barrier precautions and proper infection control procedures
These violations collectively demonstrate systemic failures in the facility's infection prevention program. The Centers for Disease Control and Prevention emphasizes that nursing homes face unique infection control challenges due to residents' increased vulnerability, close living quarters, and frequent use of invasive medical devices. Proper implementation of infection control measures becomes even more critical in these settings to protect vulnerable populations from potentially life-threatening complications.
The nursing home's infection preventionist acknowledged several areas needing improvement, including better processes for personal supply replacement and more consistent implementation of barrier precautions for at-risk residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Norton from 2025-03-05 including all violations, facility responses, and corrective action plans.
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