Federal inspectors documented widespread infection control failures at Windsor Care Center during a March inspection, finding staff repeatedly violated basic hygiene protocols that protect vulnerable residents from disease transmission.
The violations affected at least five residents at the 50-bed facility on Sterling Way. Inspectors observed staff ignoring hand hygiene requirements, sharing dirty equipment between patients, and leaving medical supplies unchanged for weeks beyond safety guidelines.
One resident's oxygen tubing bore a date of February 18, nearly a month old when inspectors found it on March 12. The facility's own policy required weekly changes to prevent bacterial growth and respiratory infections.
"Oxygen tubing that was not changed was a source of infection because of bacterial growth," the infection prevention nurse told inspectors on March 13.
The Director of Nursing confirmed that using oxygen tubing for nearly a month "could result in the user getting a respiratory infection." The facility's administrator said oxygen equipment "needed to be changed weekly or if soiled" and should be dated when replaced.
But the resident's treatment records showed inconsistent compliance. While January and February entries indicated weekly Tuesday changes, the February 18 change wasn't marked off. March records showed both Tuesdays marked for tubing changes, suggesting staff were documenting work they hadn't performed.
The same resident's humidification water bottle contained no date marking at all.
Staff hygiene failures extended beyond medical equipment to basic food service. On March 11, inspectors watched two nursing aides distribute lunch trays to three residents without sanitizing their hands between deliveries. The next day, a third aide touched one resident's food with ungloved hands and performed no hand hygiene.
When interviewed, both aides from the first incident acknowledged they should have used alcohol-based hand gel or washed with soap and water between each tray delivery.
The infection prevention nurse explained staff should sanitize between each tray and wash hands with soap after every third delivery. "If a resident's food was touched, the staff member should wear gloves," she said.
The Administrator said his expectation was "that staff should keep their hands clean and not touch the food when distributing meal trays to the residents."
More serious breaches occurred when staff handled equipment used on patients with infectious diseases. On March 12, inspectors watched two nursing aides provide care to a resident on droplet precautions for influenza. When they left the room, one aide carried the used, uncleaned gait belt and put it in her pants pocket.
The facility's list showed 19 residents on isolation precautions, including the flu patient who had been admitted the day before with an influenza diagnosis.
Nursing aides gave conflicting accounts of gait belt cleaning procedures. One said she didn't clean her belt between residents. Another claimed she washed hers at home after shifts and used antibacterial spray during work. A third said she sanitized with disinfectant wipes between each use.
The aide caught carrying the contaminated belt told inspectors she planned to clean it with sanitizing wipes at the nurses' station, then put it back in her pocket.
"It was important not to place a dirty shared equipment and a clean shared equipment in the same place to prevent the spread of infection," her colleague said, apparently unaware her partner had just done exactly that.
The infection prevention nurse said staff had received "a lot of verbal and hands on education regarding cleaning shared equipment because the facility had gone through this on the last survey." She emphasized that aides "were expected to clean them with sani-wipes after each use" to prevent transmitting infections between residents.
Perhaps the most egregious violation involved wound care for a resident with multiple pressure ulcers. On March 12, inspectors watched a licensed practical nurse perform treatment on open sores across the patient's hip, abdomen, and shoulder.
The nurse sanitized her hands and put on gloves before cleaning one pressure ulcer with saline. But when she removed those gloves to put on a new pair, she skipped hand hygiene entirely. She applied zinc cream to the first wound, then moved to treat other open sores on different body parts without changing gloves or washing hands between sites.
"Hand hygiene should be done prior to, during, and throughout wound care," the nurse acknowledged when questioned. She admitted she should have sanitized each time she changed gloves "but there was not any in the room, so she did not."
She also said she should have changed gloves when moving between different wound sites "to prevent contamination of the wounds."
The facility's policies clearly outlined these requirements. The hand hygiene policy stated staff should sanitize "before and after applying personal protective equipment such as gloves" and "when moving from a contaminated body site to a clean body site." It emphasized that "the use of gloves did not replace hand hygiene."
Even laundry operations violated infection control standards. On March 13, inspectors found staff handling dirty and soiled linens without wearing protective gowns.
The Environmental Supervisor said gloves were used for dirty laundry, but gowns were "only used for laundry from COVID rooms." He didn't know what the facility policy required for protective equipment with contaminated linens.
The Laundry and Housekeeping Supervisor gave the same account, saying gowns were used only for COVID patient linens and she wasn't aware of policy requirements for other contaminated materials.
The facility's personal protective equipment policy stated that "all staff who have contact with resident and/or their environments must wear PPE equipment as appropriate during resident care and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely."
The laundry policy specified that staff should "consider all previously worn clothing and used linens as potentially contaminated."
Throughout the inspection, administrators expressed expectations that contradicted observed practices. The Director of Nursing said it was "her expectation that staff follow policies and procedures to keep infections down." The Administrator said he maintained oversight of quality assurance and expected staff to properly clean shared equipment "to prevent infection and any kind of cross contamination."
But the infection prevention nurse revealed she had stopped performing audits of equipment cleaning and hand hygiene that were required from the previous survey. She said she no longer conducted these oversight activities that had been implemented for at least three months following earlier violations.
The nurse said "it was her expectation that staff follow policies and procedures to keep infections down" and that "all the appropriate people attended QAPI meetings for QAPI to be successful." But expectations without verification had clearly failed to prevent the widespread hygiene breakdowns inspectors documented across multiple departments and shifts.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Care Center from 2025-03-13 including all violations, facility responses, and corrective action plans.