EAST WINDSOR, NJ - Federal inspectors documented multiple infection control violations at Meadow Lakes nursing home during a March 2025 inspection, citing the facility for improper wound care procedures and widespread hand hygiene failures that potentially compromised resident safety.
Critical Infection Control Breaches During Wound Treatment
The most concerning violation occurred when inspectors observed a licensed practical nurse (LPN) treating a stage 4 pressure ulcer on a resident's sacral area without following proper infection control protocols. The resident had a deep wound reaching muscles, ligament and bone that required specialized care.
During the March 14 observation, the LPN removed soiled dressing and gloves but failed to perform hand hygiene before putting on clean gloves to continue the wound treatment. When the LPN needed scissors to cut calcium alginate wound packing, a certified nursing aide retrieved the scissors with contaminated gloves and handed them directly to the nurse.
The LPN was about to insert the wound packing material when the inspector intervened, asking whether the scissors had been disinfected. Only then did the nurse properly disinfect the instruments before continuing the procedure.
The breach in sterile technique during wound care represents a serious infection control failure. Stage 4 pressure ulcers create an open pathway for bacteria to enter deep tissue layers and potentially cause life-threatening infections. Proper hand hygiene between each step of wound care serves as a critical barrier against introducing harmful microorganisms into vulnerable tissue.
Following the observation, the LPN acknowledged missing essential steps during the wound treatment. "She should have washed her hands after removing the soiled dressing prior to applying a clean pair of gloves," according to the inspection report.
Expired CPR Certification During Resident Death
The facility also failed to ensure nursing staff maintained current cardiopulmonary resuscitation (CPR) certifications, a deficiency that came to light during a resident death. When Resident #18 was found unresponsive without pulse or respiration on the evening shift, the supervising registered nurse (RN) confirmed the death.
During questioning about her qualifications, the RN discovered her CPR certification had expired. She initially believed it was current until September but found it had already lapsed when she checked her phone during the inspector interview.
The nursing home administrator was unaware of the expired certification and could not provide a complete list of staff CPR certifications because "only the former Director of Nursing had access to it." This administrative gap meant the facility could not verify whether CPR-trained staff were available on each shift as required.
Current CPR certification ensures nursing staff can respond effectively during cardiac emergencies. The American Heart Association updates CPR guidelines regularly based on scientific evidence, making ongoing certification essential for maintaining life-saving skills.
Widespread Hand Hygiene Failures During Meal Service
Inspectors documented extensive hand hygiene violations during a lunch observation that involved multiple staff members and affected several residents. The violations created cross-contamination risks between clean food preparation and soiled items.
A dietary staff member served soup to residents while wearing gloves, then returned to the kitchen without removing gloves or washing hands. The same worker later plated meals, served residents, removed dirty dishes, and handled food items while wearing the same contaminated gloves throughout the entire meal service.
The hand hygiene dispenser adjacent to the dining room was empty during the meal service, preventing staff from following proper protocols even if they had attempted to do so.
Certified nursing aides also contributed to the contamination risks. One aide assisted a resident with feeding, then handled cups and utensils for other residents, cut food with a knife, and removed dirty dishes without performing hand hygiene between any of these tasks.
When questioned about the practices, the dietary staff member stated she "did not change the gloves because I go fast" and believed hand hygiene was unnecessary because she was "not leaving the dining room."
Medical Significance of Infection Control Violations
These infection control failures pose serious health risks to nursing home residents, who often have compromised immune systems due to age, chronic conditions, and medication effects. Cross-contamination during wound care can introduce antibiotic-resistant bacteria into deep tissue, potentially causing sepsis or osteomyelitis (bone infection).
Hand hygiene violations during meal service create pathways for foodborne illness transmission. Nursing home residents face higher risks from foodborne pathogens due to reduced stomach acid production, slower immune responses, and underlying health conditions that impair their ability to fight infections.
The Centers for Disease Control and Prevention identifies hand hygiene as the single most important practice for preventing healthcare-associated infections. Proper hand washing removes harmful microorganisms before they can spread between residents through direct contact or contaminated surfaces.
Quality Assurance Program Deficiencies
Beyond the immediate infection control violations, inspectors found the facility's Quality Assurance and Performance Improvement (QAPI) program lacked measurable goals and systematic monitoring. The administrator acknowledged that call bell response times had been identified as a concern but admitted the improvement goals were "not measurable."
The facility had initiated QAPI plans for staff education compliance and resident weighing consistency but could not provide documentation showing specific, measurable outcomes. When asked about falls with major injury - classified as adverse events - the administrator stated these incidents were "not reviewed in QAPI."
This administrative deficiency suggests systemic problems in identifying, tracking, and correcting care quality issues before they affect resident safety.
Regulatory Standards and Expectations
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs. These standards mandate proper hand hygiene, sterile technique during invasive procedures, and environmental controls to prevent disease transmission.
The facility's own policies outlined correct procedures for wound care and hand hygiene during food service, indicating staff were aware of requirements but failed to follow them consistently. This gap between written policy and actual practice represents a significant compliance failure.
The violations occurred across multiple departments - nursing, dietary, and administration - suggesting widespread implementation problems rather than isolated incidents.
Facility Response and Corrective Actions
Following the inspection, facility leadership acknowledged the violations and provided documentation showing staff had received infection control training. The Director of Nursing presented records indicating the dietary staff member had been "in-serviced on hand hygiene" on February 13, 2025, just weeks before the violations were observed.
The facility must submit a plan of correction addressing each cited deficiency and demonstrating how similar violations will be prevented in the future. State survey agencies will conduct follow-up visits to verify implementation of corrective measures.
These citations highlight ongoing challenges in nursing home infection control, particularly as facilities continue managing residents with complex medical conditions requiring specialized care protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadow Lakes from 2025-03-18 including all violations, facility responses, and corrective action plans.
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