Cherokee Center for Nursing and Healing in Canton, Georgia, faced federal citations for infection prevention and control failures during a March 2025 inspection.
CANTON, GA - Federal inspectors documented multiple infection control violations at Cherokee Center for Nursing and Healing during a March 14, 2025 survey, finding staff failed to follow basic hygiene protocols during medication administration and blood sugar monitoring.
Hand Hygiene Protocol Failures
The inspection revealed systematic failures in hand hygiene practices among licensed practical nurses (LPNs) during routine care procedures. These violations directly contradicted the facility's own infection control policies, which clearly state that staff must "perform hand hygiene before donning gloves and after removal."
During observation of blood sugar monitoring for a diabetic resident, an LPN applied gloves without first sanitizing or washing hands, then removed the gloves after obtaining the blood glucose reading without performing hand hygiene. The same nurse then handled a germicidal wipe to clean the glucometer without first applying gloves, creating multiple opportunities for cross-contamination.
When questioned by inspectors, the LPN acknowledged knowing the correct protocol, stating she should sanitize or wash hands before applying gloves and after removing them, and should wear gloves when obtaining germicidal wipes for equipment cleaning.
Medication Administration Safety Concerns
Inspectors also documented unsafe medication handling practices during routine medication administration. A nurse was observed stacking medication cups containing different medications - one cup held multiple oral medications while another contained liquid Enulose (lactulose). This practice violated facility policy and created contamination risks.
The nurse involved acknowledged to inspectors that medication cups should not be stacked, recognizing it as "a contamination issue." The facility's Director of Nursing confirmed that staff should use designated Styrofoam trays from medication carts rather than stacking medication cups.
Medical Significance of Violations
Hand hygiene represents the most fundamental infection prevention measure in healthcare settings. Failure to perform proper hand hygiene before and after glove use can facilitate transmission of healthcare-associated infections between residents and surfaces.
Gloves provide a barrier against contamination but become ineffective when hands are already contaminated before application. Similarly, removing contaminated gloves without subsequent hand hygiene transfers pathogens to hands, which then contaminate every subsequent surface touched.
The stacking of medication cups presents risks of medication contamination and potential dosing errors. Liquid medications can leak or transfer residue to adjacent containers, potentially altering medication concentrations or introducing unwanted substances.
Blood Glucose Monitoring Protocols
Blood glucose monitoring requires strict infection control measures due to the invasive nature of fingerstick procedures. Proper protocol requires hand sanitization, glove application, blood sampling, equipment cleaning with appropriate disinfectants while wearing gloves, glove removal, and final hand sanitization.
The observed practice of cleaning the glucometer with bare hands using germicidal wipes violates multiple safety principles. Glucometers can harbor bloodborne pathogens from previous use, making gloved handling essential during cleaning procedures.
Facility Policies vs. Practice
The facility maintained comprehensive infection control policies that clearly outlined proper procedures. The Personal Protective Equipment policy, reviewed in January 2025, specifically addressed glove use and hand hygiene requirements. The Blood Glucose Monitoring policy, updated in February 2025, detailed cleaning and disinfection requirements for glucometers.
These documented policies met regulatory standards, but the inspection revealed significant gaps between written protocols and actual practice. The Director of Nursing demonstrated knowledge of correct procedures when interviewed, indicating the issue lay in policy implementation and staff compliance rather than inadequate guidance.
Resident Impact Assessment
The violations affected residents with complex medical conditions requiring careful infection prevention. One affected resident had multiple chronic conditions including chronic obstructive pulmonary disease, congestive heart failure, and malignant neoplasm of the prostate. The other resident had Type 2 diabetes requiring regular blood glucose monitoring.
Both residents maintained intact cognition according to their assessments, making them aware of care procedures and potentially concerned about observed safety lapses. Residents with multiple chronic conditions face elevated risks from healthcare-associated infections due to compromised immune systems.
Regulatory Standards and Expectations
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs. These programs must include staff training, policy development, and ongoing monitoring to ensure consistent implementation of safety measures.
The observed violations represent failures in basic infection control principles that form the foundation of safe healthcare delivery. Hand hygiene compliance, proper use of personal protective equipment, and safe medication handling are fundamental requirements in all healthcare settings.
Facility Response Requirements
The facility must develop and implement corrective action plans addressing each identified deficiency. This typically includes retraining affected staff members, implementing monitoring systems to ensure ongoing compliance, and establishing quality assurance measures to prevent recurrence.
The Director of Nursing's accurate knowledge of proper procedures suggests the facility has appropriate policies in place but requires improved oversight of daily implementation. Effective corrective action should focus on bridging the gap between policy knowledge and consistent practice.
The inspection classified these violations as causing "minimal harm or potential for actual harm," affecting few residents. However, infection control failures can have serious consequences if not promptly addressed, as they create conditions that facilitate disease transmission throughout healthcare facilities.
Healthcare facilities must maintain constant vigilance regarding infection prevention, as even seemingly minor protocol violations can contribute to serious adverse outcomes. The Cherokee Center inspection highlights the importance of consistent adherence to established safety protocols in protecting resident health and wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brian Center Health & Rehabilitation/canton from 2025-03-14 including all violations, facility responses, and corrective action plans.
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