DELRAY BEACH, FL - Federal inspectors documented serious infection control breaches and an ineffective medication error monitoring program at West Delray Nursing & Rehab Center during a March 2025 survey, revealing failures that could compromise resident safety and health.
Infection Control Protocols Compromised
The most significant violations centered on the facility's failure to follow Centers for Disease Control and Prevention (CDC) guidelines for standard precautions, potentially exposing vulnerable residents to infectious diseases and hospital-acquired infections.
During the inspection, surveyors observed a certified nursing assistant using the same pair of gloves for multiple contaminated tasks while caring for a resident with multiple sclerosis and diabetes. The staff member was seen handling trash removal, adjusting meal tables, touching the resident's hair and head, arranging bed linens, and assisting with personal care - all without changing gloves between these activities.
This cross-contamination scenario represents a fundamental breach of infection control protocols. Standard precautions require healthcare workers to change gloves between different tasks and patients to prevent the spread of pathogens. When gloves are worn for extended periods across multiple activities, they become vehicles for transmitting bacteria, viruses, and other microorganisms rather than protective barriers.
The violation becomes particularly concerning given the resident's medical conditions, including diabetes, which can compromise immune system function and increase susceptibility to infections. Multiple sclerosis patients may also have reduced mobility and weakened immune responses, making proper infection control critical for their wellbeing.
Medical Equipment Contamination Risks
Equally troubling were observations of nursing staff failing to disinfect vital signs equipment between residents. During the inspection, a registered nurse was observed using blood pressure cuffs and oxygen saturation monitors on multiple residents without proper cleaning or disinfection between uses.
The nurse removed a blood pressure cuff that had been used on one resident and immediately applied it to another resident's arm without any disinfection. Similarly, the oxygen saturation clip was transferred between residents without cleaning. After completing vital signs, the equipment was returned to the mobile cart without disinfection, where another resident was later observed touching the contaminated surface.
This practice violates fundamental healthcare safety protocols and creates significant infection transmission risks. Medical equipment that contacts patients' skin can harbor dangerous pathogens, including antibiotic-resistant bacteria such as MRSA (methicillin-resistant Staphylococcus aureus) and VRE (vancomycin-resistant enterococci). When contaminated equipment is used on multiple patients, it can rapidly spread these organisms throughout a healthcare facility.
The risk is amplified in nursing home settings where residents often have compromised immune systems, chronic conditions, and open wounds that provide entry points for infections. One of the affected residents had recently been hospitalized for multiple conditions including multi-drug resistant Klebsiella urinary tract infection and respiratory syncytial virus, making proper equipment disinfection essential to prevent reinfection or transmission to other residents.
Medical Consequences of Infection Control Failures
Healthcare-associated infections represent a major threat in long-term care facilities, where residents typically have multiple risk factors including advanced age, chronic diseases, reduced mobility, and potential immunocompromising conditions. When infection control protocols fail, residents face increased risks of:
Respiratory tract infections, which can be particularly dangerous for residents with chronic obstructive pulmonary disease, heart failure, or compromised lung function. Cross-contamination through improperly cleaned oxygen saturation equipment could facilitate transmission of respiratory pathogens.
Skin and soft tissue infections from contaminated blood pressure cuffs and direct contact with unwashed gloves. These infections can progress to serious systemic conditions, especially in residents with diabetes or circulation problems.
Urinary tract infections and sepsis, which are leading causes of hospitalization and mortality in nursing home residents. Contaminated equipment and poor hand hygiene practices significantly increase transmission risks.
The CDC estimates that healthcare-associated infections affect approximately 1 in 31 hospital patients on any given day, with nursing home residents facing similar or higher risks due to their vulnerability and communal living environment.
Quality Assurance Program Inadequacies
Beyond infection control, inspectors identified failures in the facility's Quality Assurance and Performance Improvement (QAPI) program, specifically regarding medication error monitoring. Federal regulations require nursing homes to maintain medication error rates below 5%, but the facility's quality assurance system was deemed ineffective in achieving this standard.
The inspection revealed that while the facility had implemented corrective measures in April 2025, including staff re-education on medication administration and observation records by the consultant pharmacist, the overall QAPI program had not successfully prevented medication errors from exceeding acceptable thresholds.
Medication errors in nursing homes can have serious consequences for residents, including adverse drug reactions, therapeutic failures, and potential hospitalizations. Common types include timing errors, wrong dosages, omitted medications, and administration of medications to wrong residents. Effective quality assurance programs should identify patterns, implement corrective actions, and monitor outcomes to ensure continuous improvement.
Industry Standards and Best Practices
Healthcare facilities are required to implement comprehensive infection prevention and control programs based on CDC guidelines. These programs should include:
Hand hygiene protocols requiring healthcare workers to clean their hands before and after patient contact, before and after wearing gloves, and after touching potentially contaminated surfaces or equipment.
Personal protective equipment policies specifying when and how to use gloves, gowns, masks, and other protective items, including requirements for changing equipment between patients and tasks.
Environmental cleaning and disinfection procedures for all patient care equipment, including vital signs monitors, blood pressure cuffs, and other medical devices that contact multiple patients.
Staff training and competency validation to ensure all personnel understand and can properly implement infection control procedures.
Additional Issues Identified
The inspection also documented problems with medication administration timing and staff training documentation. Licensed nursing staff required re-education on proper medication administration processes, and agency nurses needed additional orientation to facility medication and treatment guidelines.
Equipment disinfection supplies were not readily available at point of use, with no disinfectant observed on the mobile vital signs cart during inspection. This lack of immediately accessible cleaning supplies creates barriers to proper infection control practices and suggests systemic problems with infection prevention program implementation.
The facility's corrective action plan included medication pass observations by the consultant pharmacist and staff re-training, indicating recognition of the problems and efforts to address deficiencies. However, the inspection findings suggest these measures may not have been sufficient to prevent ongoing compliance issues.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manorcare Health Services from 2025-03-12 including all violations, facility responses, and corrective action plans.
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