NORWALK, CA - Federal inspectors identified serious infection prevention and control failures at Southland nursing facility, including staff not wearing required protective equipment when caring for residents with contagious conditions and improper handling of medical devices.
Multiple Breaches in Infection Control Protocols
During a March 2025 inspection, Centers for Medicare & Medicaid Services surveyors documented numerous instances where staff failed to follow established infection control procedures that are designed to prevent the spread of infectious diseases among vulnerable nursing home residents.
The most significant violations involved Enhanced Barrier Precautions (EBP), which are specialized infection control measures requiring staff to wear isolation gowns and gloves when providing direct care to residents with certain medical conditions or devices. These precautions are specifically designed to reduce transmission of multi-drug resistant organisms that can cause serious infections.
Inspectors observed a certified nursing assistant providing care to a resident on EBP precautions without wearing the required isolation gown. The resident had a urinary catheter, which increases infection risk and requires enhanced protective measures. During questioning, the staff member acknowledged understanding the requirement but admitted to not following proper protocols.
"CNA 5 stated 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," according to the inspection report.
Similarly, two restorative nursing aides were observed providing range-of-motion exercises to the same resident without wearing isolation gowns. The aides told inspectors they were unaware of the resident's EBP status and had not seen proper signage indicating the precautions were required.
Critical Medical Device Safety Failures
Inspectors identified a potentially dangerous situation involving improper catheter maintenance. A resident's peripheral venous catheter - a thin tube inserted into a vein to deliver medications - was found without a required pressure cap covering the hub. This sterile cap is essential for preventing bacteria and other pathogens from entering the bloodstream.
Healthcare professionals understand that uncapped catheter hubs create direct pathways for infection to enter the circulatory system. Bloodstream infections can rapidly progress to sepsis, a life-threatening condition that is particularly dangerous for elderly nursing home residents with compromised immune systems.
Multiple licensed nurses confirmed to inspectors that pressure caps are mandatory infection control measures. The facility's own policy requires quick replacement of old caps with sterile new ones to maintain the sterile barrier that protects residents from potentially fatal infections.
COVID-19 Precaution Violations
The inspection revealed systematic failures in COVID-19 infection control protocols. Multiple staff members were observed entering and exiting a COVID-19 isolation room without proper personal protective equipment, potentially exposing themselves and other residents to the virus.
Federal guidelines require comprehensive protective equipment including gowns, eye protection, fitted respirators, and gloves when caring for COVID-19 patients. The protocols also mandate specific procedures for putting on and removing protective equipment, plus hand sanitization before entering and after leaving isolation rooms.
Inspectors documented housekeeping staff entering COVID rooms wearing only masks and gloves, missing required gowns and eye protection. Nursing assistants were observed failing to change masks after leaving COVID rooms and not performing required hand hygiene. One staff member was seen touching surfaces inside a COVID room without proper protective equipment.
These violations occurred despite the facility's written policies requiring proper protective equipment and procedures for COVID-19 isolation rooms.
Delayed Response to Contagious Skin Condition
The facility failed to promptly isolate a resident diagnosed with scabies, a highly contagious skin condition caused by mites. Medical records show the dermatologist diagnosed scabies and prescribed treatment medication on February 3, 2025, but the facility did not implement required contact isolation precautions until February 17 - a delay of two weeks.
Scabies spreads through direct skin-to-skin contact and can rapidly transmit among nursing home residents through routine care activities, shared linens, and close proximity. The delay in implementing isolation precautions potentially exposed other residents, staff members, and visitors to the parasitic infection.
Healthcare protocols require immediate isolation when scabies is diagnosed to prevent outbreak conditions in congregate care settings. The facility's infection prevention nurse acknowledged that isolation should have been implemented immediately upon diagnosis.
Medical Context and Health Implications
Infection control measures in nursing homes serve as critical barriers against disease transmission among highly vulnerable populations. Elderly residents typically have weakened immune systems, multiple chronic conditions, and limited ability to fight off infections that healthy adults might easily overcome.
Enhanced Barrier Precautions specifically target multi-drug resistant organisms - bacteria that don't respond to standard antibiotic treatments. These "superbugs" can cause infections that are extremely difficult to treat and often lead to serious complications or death in nursing home residents.
Proper catheter maintenance prevents catheter-associated bloodstream infections, which occur when bacteria migrate along the catheter into the bloodstream. These infections carry mortality rates of 12-25% in elderly patients and can lead to extended hospitalizations, increased healthcare costs, and reduced quality of life.
COVID-19 remains particularly dangerous for nursing home populations, with higher rates of severe illness, hospitalization, and death compared to younger adults. Proper isolation and protective equipment protocols are essential for preventing facility-wide outbreaks that can affect dozens of residents simultaneously.
Additional Issues Identified
Beyond the major infection control failures, inspectors documented problems with antibiotic stewardship oversight, incomplete vaccination documentation and education, environmental safety concerns during maintenance work, and pest control deficiencies including cockroaches observed in resident rooms.
The antibiotic stewardship violations involved failure to properly evaluate whether prescribed antibiotics met established clinical criteria, potentially contributing to antibiotic resistance development. Vaccination documentation gaps left uncertainty about residents' protection against preventable diseases like influenza and pneumonia.
These interconnected deficiencies suggest systemic challenges in maintaining comprehensive infection prevention and safety protocols throughout the facility's operations.
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.
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