SUPERIOR, WI - Federal inspectors at Superior Rehabilitation Center LLC documented serious violations involving infection control breaches and improper medical equipment sharing that potentially exposed vulnerable residents to dangerous infections, according to a March 2025 inspection report.
Critical Infection Control Violations Put Residents at Risk
The most concerning violation involved staff sharing a contaminated wheelchair between residents despite knowing one had an active C. difficile infection. The incident occurred when a resident requiring a bariatric wheelchair for a medical appointment was given equipment previously used by a resident with C. diff, a potentially deadly bacterial infection that spreads through contaminated surfaces.
A nursing assistant interviewed by inspectors revealed the dangerous decision-making process: "I knew [the other resident] had C. Diff. They told me to clean the wheelchair before I used it... I was not going to be responsible for someone getting C. diff because I didn't clean the chair properly." The aide reported that when administrators cleaned the wheelchair, they failed to use proper bleach disinfection, instead using only standard cleaning wipes.
C. difficile infections cause severe diarrhea and colitis, with particularly high mortality rates among elderly nursing home residents. The bacteria forms hardy spores that survive on surfaces for months and require specific bleach-based disinfection protocols. Cross-contamination through shared medical equipment represents one of the most common transmission pathways in healthcare facilities.
The Centers for Disease Control recommends dedicated equipment for residents with C. diff infections, or rigorous disinfection with EPA-approved sporicidal agents when sharing is unavoidable. Standard cleaning wipes are insufficient to eliminate C. diff spores, making the facility's cleaning protocol inadequate for preventing transmission.
Dangerous Hygiene Practices During Personal Care
Inspectors documented a disturbing pattern of infection control failures during intimate personal care procedures. Staff were observed providing hygiene assistance without proper protective equipment and failing to follow basic hand sanitization protocols.
In one documented incident, a nursing assistant was observed cleaning a resident's groin and buttock area with bare hands, then continuing to touch the resident's face, clothing, and wheelchair without changing gloves or sanitizing hands. The same contaminated gloves were worn while transporting the resident to the dining room and arranging furniture, potentially spreading bacteria throughout common areas.
When questioned about proper procedures, the nursing assistant demonstrated knowledge of correct protocols but admitted to not following them: "CNA U indicated that CNA U should have applied gloves the first time before cleaning [the resident's] peri area, then sanitized hands after and before placing gloves on."
Personal care procedures in nursing homes require strict adherence to infection control protocols because residents often have compromised immune systems and multiple chronic conditions. Proper glove use and hand hygiene during intimate care prevents the spread of healthcare-associated infections, including urinary tract infections, skin infections, and gastrointestinal illnesses that can be life-threatening for elderly residents.
Unsanitary Conditions in Bathing Facilities
The inspection revealed concerning hygiene issues in shower rooms that serve multiple residents daily. Inspectors found clean linens stored inappropriately on shower railings, inside shower stalls, and on benches where they could become contaminated. Personal care items including soap bars and razors were left in open containers within shower areas.
Multiple nursing assistants confirmed these practices were routine, with one stating that extra clean linens were regularly left in shower rooms, though staff acknowledged that once left there, the linens would need to be considered contaminated and sent to laundry.
Proper linen management in healthcare facilities requires clean textiles to be stored in enclosed, designated areas away from moisture and potential contamination sources. Shower environments present particular risks due to high humidity, splash contamination, and the presence of bacteria and other microorganisms. Leaving clean linens exposed in these areas violates basic infection prevention principles and wastes facility resources.
The presence of shared personal care items like soap bars creates additional infection risks, as these products can harbor bacteria and facilitate transmission between residents. Current healthcare standards recommend individual, disposable personal care products for each resident to prevent cross-contamination.
Vaccination Documentation Failures
The facility failed to maintain proper documentation regarding influenza and pneumococcal vaccinations for multiple residents with severe cognitive impairment. Despite facility policies requiring annual vaccination offers and documentation of acceptance or refusal, medical records lacked evidence that residents were properly offered these critical preventive measures.
For residents with dementia and Alzheimer's disease, vaccination becomes even more important due to their increased vulnerability to respiratory infections and potential complications. Pneumococcal disease and influenza can cause severe complications in elderly populations, including pneumonia, sepsis, and death.
Federal regulations require nursing homes to offer these vaccines annually and document the resident's response, whether acceptance, refusal, or medical contraindication. This documentation serves both as a quality assurance measure and legal protection for facilities while ensuring residents receive appropriate preventive care.
Medical Context and Health Implications
These violations represent fundamental breakdowns in infection prevention and control systems that protect nursing home residents from healthcare-associated infections. Elderly residents in long-term care facilities face significantly higher risks from infectious diseases due to age-related immune system decline, multiple chronic conditions, and frequent use of antibiotics that can disrupt normal bacterial flora.
C. difficile infections pose particular dangers in nursing home settings, with mortality rates reaching 15-25% in severe cases among elderly patients. The bacteria's ability to form spores that survive standard cleaning makes proper disinfection protocols essential for preventing outbreaks that can affect multiple residents and staff.
Hand hygiene failures during personal care procedures create direct transmission pathways for numerous pathogens, including antibiotic-resistant bacteria that are increasingly common in healthcare settings. These infections can lead to prolonged hospitalizations, increased healthcare costs, and significant morbidity and mortality among vulnerable residents.
Additional Issues Identified
The inspection documented several other concerning practices that compromise resident safety and care quality. These included improper storage of medical supplies, inadequate cleaning protocols in common areas, and inconsistent implementation of facility policies regarding infection prevention measures.
The facility's response to these violations will be critical in preventing future incidents and ensuring resident safety. Effective remediation typically requires comprehensive staff retraining, policy updates, enhanced monitoring systems, and administrative oversight to ensure sustained compliance with infection control standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Superior Rehabilitation Center LLC from 2025-03-13 including all violations, facility responses, and corrective action plans.
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