GLENVIEW, IL - Health inspectors documented multiple infection control violations at Abington of Glenview Nursing during an April 2025 inspection, finding staff consistently failed to properly disinfect medical equipment, use protective gear, and maintain sanitary conditions for vulnerable residents.
Medical Equipment Contamination Puts Residents at Risk
The most concerning violations involved the repeated use of contaminated medical equipment between residents. On April 1st, inspectors observed a Licensed Practical Nurse taking a portable blood pressure machine from one resident and immediately using it on another resident without any disinfection. When confronted, the nurse acknowledged that "BP equipment should be clean/disinfect before and after taking resident's BP."
This practice creates significant infection transmission risks in nursing home settings, where residents often have compromised immune systems and chronic health conditions. Medical equipment that contacts multiple residents must be properly disinfected between uses to prevent the spread of dangerous pathogens, including antibiotic-resistant bacteria that are particularly prevalent in healthcare facilities.
The facility's own policy required that "devices/equipment used for more than one resident shall be cleaned between each resident," yet this protocol was not being followed by nursing staff. Such violations can facilitate the rapid spread of infections throughout a facility, potentially causing serious illness or death among vulnerable elderly residents.
Protective Equipment Protocols Ignored for High-Risk Residents
Inspectors documented serious failures in the use of personal protective equipment (PPE) when caring for residents on Enhanced Barrier Precautions. On April 2nd, a Registered Nurse entered the room of a resident requiring enhanced precautions while wearing only a mask and gloves, failing to don the required protective gown.
The nurse later told inspectors "she did not don gown because she was just taking vital signs and performing oral administration of medication." However, facility policy clearly stated that Enhanced Barrier Precautions require both gown and gloves during "any situation where expected contact of blood, bodily fluids, skin breakdown, or mucous membrane will be encountered."
Enhanced Barrier Precautions are implemented specifically for residents who may be colonized with multi-drug resistant organisms (MDROs). These dangerous bacteria can cause life-threatening infections that are extremely difficult to treat due to their resistance to multiple antibiotics. Proper PPE use creates a crucial barrier preventing these organisms from spreading to other residents, staff, or visitors.
The violation becomes more concerning given that medical equipment used during these encounters was not properly disinfected. The facility's own disinfectant wipes required a three-minute contact time to be effective, but staff were not allowing adequate time for proper disinfection.
Hand Hygiene Lapses Create Additional Infection Pathways
Inspectors observed multiple instances of improper hand hygiene, a fundamental infection control practice. The Director of Guest Relations was seen removing gloves and proceeding directly to a resident room without performing hand hygiene. When questioned, he stated "he performed hand hygiene before putting gloves on but not after removing it."
This represents a critical break in the infection control chain. Hand hygiene after glove removal is essential because gloves can develop microscopic tears during use, potentially allowing contamination to reach the hands. Additionally, hands can become contaminated during the glove removal process itself.
The facility's own hand hygiene policy clearly required hand washing or sanitizing after glove removal, yet this basic safety protocol was not being consistently followed by staff members who have direct contact with residents.
Respiratory Equipment Storage Violations Detected
Inspectors found improper storage of nebulizer equipment used for breathing treatments. A resident receiving nebulizer therapy for pneumonitis had her nebulizer mask and tubing left exposed on the nightstand rather than being properly stored in a sealed plastic bag after cleaning and drying.
Respiratory equipment requires special attention to prevent contamination because it directly contacts the patient's airway. Improper storage can lead to bacterial or fungal growth on the equipment, which then gets inhaled directly into the lungs during the next treatment. For residents with existing respiratory conditions, this contamination can cause serious pneumonia or other lung infections.
The facility's respiratory medication policy required that nebulizer equipment be "washed with warm, soapy water daily, rinsed with hot water, allowed to air dry completely on paper towel," and then "stored in a plastic bag with resident's name and date on it." This protocol was not being followed.
Understanding the Medical Significance
These infection control failures are particularly dangerous in nursing home environments because residents typically have multiple chronic conditions, weakened immune systems, and often require extensive hands-on care. The elderly population is already at higher risk for healthcare-associated infections, which can quickly become life-threatening.
Healthcare-associated infections affect approximately 1.7 million residents in long-term care facilities annually, according to federal health data. These infections can lead to serious complications including sepsis, pneumonia, and urinary tract infections that may require hospitalization or can be fatal.
Multi-drug resistant organisms, which the Enhanced Barrier Precautions were designed to contain, pose an especially serious threat. These "superbugs" have become increasingly common in healthcare settings and can cause infections that are extremely difficult or impossible to treat with standard antibiotics.
Additional Issues Identified
The inspection revealed several other concerning practices that compromised infection control standards. Inspectors found a dirty emesis basin with dried toothpaste residue placed directly next to a urinary drainage bag in a resident's bathroom, creating potential for cross-contamination between different bodily fluids.
Staff members were also found to be inconsistent in their understanding of proper disinfection protocols. The Infection Preventionist told inspectors that "vital signs equipment is only disinfected after using and not before," contradicting the Director of Nursing who stated that equipment should be disinfected both before and after use.
This confusion among leadership staff about basic infection control protocols suggests systemic issues with staff training and policy implementation throughout the facility.
The violations documented during this inspection demonstrate concerning gaps in fundamental infection control practices that are essential for protecting resident health and safety in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Abington of Glenview Nursing from 2025-04-04 including all violations, facility responses, and corrective action plans.
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