The March incident at Southland nursing home illustrates widespread infection control failures that federal inspectors documented during a complaint investigation. Staff repeatedly entered rooms of residents with COVID-19, scabies, and other infectious conditions without proper protective equipment, creating risks for disease transmission throughout the facility.
Certified Nursing Assistant 5 put on gloves but skipped the required isolation gown when Resident 8 complained of abdominal and buttock pain on March 11. The assistant walked to the bed, removed blankets, touched the resident's abdomen and legs, repositioned the catheter, and replaced the blankets before leaving.
"She should have worn an isolation gown while assisting Resident 8 with care because she had direct contact with Resident 8 who was on EBP precautions," CNA 5 told inspectors the next day. Enhanced Barrier Precautions require gowns and gloves during high-contact care activities to reduce transmission of multi-drug resistant organisms.
The same resident received physical therapy exercises from two restorative nursing aides who also failed to wear isolation gowns. RNA 1 and RNA 2 worked on the resident's arms while wearing only gloves, not the full protective equipment required for someone on enhanced precautions.
"They did not see the sign indicating Resident 8 was on EBP precautions and did not see a PPE storage container upon entrance to Resident 8's room," the aides explained to inspectors.
In another room, Resident 268 sat with a peripheral venous catheter on her right hand completely uncapped. The catheter hub, which provides access for medications and fluids, lacked the sterile pressure cap designed to prevent pathogens from entering the bloodstream.
Licensed Vocational Nurse 8 acknowledged during the inspection that "there should have been a pressure cap to cover the hub of the catheter for infection control preventing pathogens from entering the hub."
COVID-19 protocols broke down repeatedly at Southland. Resident 26 was diagnosed with the virus on March 10 and placed on respiratory, droplet, and contact precautions the following day. The precautions require staff to wear gowns, eye protection, fit-tested respirators, and gloves before entering the room.
Instead, inspectors watched a parade of inadequately protected staff enter and exit. Housekeeping Staff 1 brought supplies wearing only a mask and gloves. Certified Nursing Assistant 2 delivered breakfast in the same incomplete gear. Another housekeeper touched curtains inside the room while wearing just a mask and gloves, then forgot to sanitize her hands when leaving.
Two more nursing assistants entered without eye protection. One walked away without sanitizing her hands, while the other failed to change her mask upon leaving.
"She supposed to wear proper PPE prior to enter the COVID precaution room," CNA 2 admitted to inspectors.
The facility's scabies response proved equally problematic. Resident 26 developed a rash on her legs during a dermatology visit on January 27. The dermatologist sent a skin sample for testing and received confirmation of scabies on February 3, immediately prescribing permethrin treatment.
But Southland waited two weeks to isolate the resident. The facility didn't implement contact precautions until February 17, despite receiving the positive scabies diagnosis on February 3.
"The facility should had placed the resident on contact isolation on 2/3/2025 when the physician diagnosed the resident with scabies and ordered permethrin to prevent the spread of the disease, not only for the resident but also for the staff, visitors, and anyone who made contact with her or her linens," Licensed Vocational Nurse 7 told inspectors.
During that two-week delay, the contagious skin condition could have spread to other residents, staff, and visitors through direct contact.
Other infection control lapses included a licensed vocational nurse who changed a feeding tube for a resident on enhanced precautions while wearing gloves and a mask but no gown. The resident's room also lacked the required signage indicating special precautions were in effect.
Inspectors found non-laundry items mixed in with clean linens in the laundry room, violating basic sanitation protocols.
The facility's own policies require gowns and gloves for high-contact care of residents on enhanced barrier precautions, proper capping of catheter hubs to prevent infection, and immediate isolation of residents with contagious conditions like scabies.
Director of Nursing acknowledged the importance of following infection control protocols. "It was important all staff followed the proper infection control protocols to prevent the spread of infection," she told inspectors.
The failures occurred at a 120-bed facility that has operated in Norwalk since the 1970s. Federal inspectors also cited Southland for pest control violations after finding a cockroach in a resident's bathroom.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southland from 2025-03-14 including all violations, facility responses, and corrective action plans.