The March inspection at Middleton Oaks Health and Rehabilitation revealed widespread failures in infection control practices that federal regulators say put residents at risk. Staff performed wound care without protective equipment, stored medical drainage bags on floors, and had never been trained on enhanced barrier precautions designed to prevent the spread of infections.
Licensed Practical Nurse #4 discovered Resident #75's feeding tube was clogged during medication administration on March 26. She retrieved an opened, undated package from the bedside table containing a feeding tube declogger and inserted the device into the resident's tube multiple times. After unclogging the tube, she rinsed the declogger and placed it back in the package.
When inspectors showed her the manufacturer's instructions online, LPN #4 confirmed the device was labeled for single use only. She acknowledged that reusing the declogger placed Resident #75 at risk for infection. The nurse also admitted she had never been trained on enhanced barrier precautions and did not wear protective equipment during the medication administration.
The Regional Director of Clinical Services told inspectors on March 26 that staff "should not be using feeding tube de-cloggers" and said there were other alternatives for handling clogged tubes.
Multiple staff members performed wound care throughout the facility without following enhanced barrier precautions that require gowns and gloves during high-contact activities like wound treatment. The facility's own policy, effective September 2022, specifically identifies wound care as a high-contact activity that provides opportunities for multidrug-resistant organisms to transfer to staff hands and clothing.
The Wound Care Registered Nurse and Certified Nursing Assistant #5 treated Resident #11's sacral pressure ulcer on March 26 without using any enhanced barrier precautions. The wound care nurse told inspectors the next day she was "unaware of the EBP guidelines and did not dress out during her wound care treatments."
Resident #11 was admitted in December 2023 with diagnoses including pressure ulcer to the sacral region and type 2 diabetes. Assessment records from February showed the resident was rarely or never understood.
The same pattern repeated with other residents. During wound care for Resident #25's unstageable pressure ulcer on the tip of his left great toe, staff again failed to wear protective gowns. The wound care nurse and assistant confirmed they had no knowledge of enhanced barrier precautions and had never been trained on the requirements.
Resident #25 was admitted in September 2023 with metabolic encephalopathy. His treatment orders called for cleaning the wound with normal saline, painting it with betadine, and covering it with bordered gauze three times per week.
Staff treating Resident #32's diabetic heel wound also skipped protective equipment during the March 26 procedure. The wound care nurse and assistant confirmed they wore no special personal protective equipment and had not received training on enhanced barrier precautions.
Four certified nursing assistants interviewed by inspectors confirmed they had never been trained on enhanced barrier precautions and had no knowledge of the requirements.
The facility's Infection Control Nurse revealed she knew about enhanced barrier precautions from her training but confirmed the facility was not using them for any residents. She said she was unaware why the facility had not educated staff or implemented the practice.
Beyond wound care violations, inspectors found a biliary drainage collection bag containing brown, foamy substance lying on the floor of Resident #65's room, visible from the doorway. The resident had been admitted March 9 with pancreatic cancer and bile duct obstruction, with biliary drain orders starting February 28.
Licensed Practical Nurse #2 confirmed the drainage bag should not be on the floor and called it an infection control issue. "The floor is the nastiest place!" she told inspectors.
The Assistant Director of Nursing agreed the biliary drainage bag on the floor posed an infection control concern that could lead to resident infection.
Administrator interviews revealed the facility had previously used enhanced barrier precautions but experienced "a breakdown in its practice due to significant staff turnover in the past six months." On March 26, the administrator said he was not aware staff were not using the precautions.
During a follow-up interview, the administrator confirmed that failing to educate staff and implement enhanced barrier precautions meant "high-risk residents would not receive the necessary precautions."
The Regional Director of Clinical Services acknowledged on March 26 that the facility was "currently working on getting EBP into place" and confirmed staff had not been educated on the precautions. She confirmed the purpose of enhanced barrier precautions was to protect residents from infection.
Record review revealed the facility had an Enhanced Barrier Precautions policy effective September 2022 stating the precautions should be used to reduce the spread of multidrug-resistant organisms among residents. The policy specifically identified feeding tube care and wound care as high-contact activities requiring enhanced precautions.
The facility's broader Infection Prevention and Control Program policy, revised in October 2018, stated the program was established "to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections."
Inspectors noted the facility had no policy on storage of biliary tube bags.
The violations affected multiple residents across different units and involved various staff members, from licensed nurses to certified nursing assistants. Federal inspectors classified the deficiencies as having potential for actual harm to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Middleton Oaks Health and Rehabilitation from 2025-03-27 including all violations, facility responses, and corrective action plans.
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