NORTH MANCHESTER, IN - A federal inspection at Peabody Retirement Community revealed widespread failures in infection control practices, with staff repeatedly entering the rooms of residents with contagious respiratory illnesses without proper protective equipment and neglecting basic hand hygiene protocols.
The April 2025 survey documented infection control violations affecting 6 of 9 residents reviewed who were on droplet precautions for conditions including Influenza A, pneumonia, and bronchitis. Inspectors noted the deficient practices had the potential to affect all 38 residents at the facility who had orders for droplet precautions during the review period.
Staff Entered Isolation Rooms Without Required Eye Protection
The most consistent violation documented throughout the inspection involved staff entering residents' rooms without wearing the eye protection clearly required by posted signage. Droplet precautions signs on resident doors explicitly stated that staff must ensure "their eyes, nose and mouth are fully covered before room entry," with images showing face shields or goggles as acceptable options.
Despite these clear instructions, inspectors observed multiple instances where staff ignored the requirement entirely.
On April 7, a certified nursing assistant entered the room of Resident 369, who was on droplet isolation for Influenza A symptoms. The CNA was not wearing eye covering during the observation and failed to perform hand hygiene upon exiting. When interviewed at the time, the staff member acknowledged the lapse, stating that "since the Personal Protective Equipment was not visible at the resident's doorway, she went into the room anyway."
Shortly after, a dietary aide also entered the same resident's room without eye protection. When questioned, the dietary aide indicated she believed that since she "had talked with the resident, she had not needed to wear any PPE while in the resident's room."
This misunderstanding of infection control protocols represents a significant gap in staff training. Droplet precautions exist specifically because respiratory infections like influenza spread through particles generated when an infected person coughs, sneezes, or even talks. Standing at a bedside and conversing with a resident with Influenza A without proper eye protection creates direct exposure to infectious droplets that can enter through the mucous membranes of the eyes.
Another staff member, CNA 6, was observed entering the room of Resident 147, who was on droplet precautions for bronchitis. While the CNA did don a gown, gloves, and placed an N95 mask over her surgical mask, she did not wear a face shield despite the posted signage requiring it. During the subsequent interview, she indicated "the facility training had indicated she did not need a face shield" for that resident.
Similarly, a qualified medication aide was observed delivering medications to Resident 29, who had pneumonia, acute respiratory failure with hypoxia, and was dependent on supplemental oxygen. The QMA donned appropriate gown, gloves, and mask but removed her eyeglasses before entering rather than adding eye protection. When interviewed, she confirmed "the facility did not require face shields/eye protection for the droplet rooms."
The facility's own Infection Preventionist contradicted these staff statements during a later interview, confirming that "eye protection was required to enter rooms with droplet precautions" and that "staff were expected to read and follow the isolation signage on the doors."
Hand Hygiene Failures Compounded Exposure Risks
Beyond the eye protection violations, inspectors documented repeated failures to perform hand hygiene when entering and exiting isolation rooms, creating pathways for pathogens to spread throughout the facility.
When a CNA exited Resident 109's room, which had droplet precautions for viral syndrome with coughing and wheezing, no hand hygiene was performed. The staff member then retrieved a mechanical lift from another area of the unit, re-entered the isolation room, and upon finally exiting, carried a bag of trash to the receptacle before eventually washing hands. This sequence created multiple touchpoints where pathogens could have been transferred to shared equipment and surfaces.
Resident 109, according to records, had diagnoses including unspecified dementia and was "rarely or never understood" and dependent on staff for bed mobility and transfers. Such residents are particularly vulnerable because they cannot advocate for their own safety or remind staff of proper protocols.
The pattern continued with Resident 15, who was on droplet precautions for Influenza A. A qualified medication aide answered the call light, entered the room, stood at the bedside speaking with the resident for several minutes, then exited without performing hand hygiene or wearing eye covering. The resident's care plan specifically indicated interventions including "all goods and services brought to resident's room" and "droplet precautions as ordered" to prevent spread.
Hand hygiene serves as one of the most fundamental and effective infection control measures in healthcare settings. The simple act of cleaning hands before entering and after leaving a patient's room can significantly reduce the transmission of respiratory pathogens. When staff skip this step after contact with residents who have confirmed Influenza A, they risk carrying the virus on their hands to other residents, shared equipment, and common areas.
Dining Room Practices Created Cross-Contamination Risks
The inspection also documented concerning infection control practices during dining services in the Evergreen Park Unit dining room, where a single staff member's actions created multiple opportunities for cross-contamination among three residents.
During a continuous observation lasting approximately 45 minutes, a CNA assisting Resident 75 with his meal was observed rubbing her nose with her left index finger, then immediately picking up the resident's fork to assist with feeding. She palmed over the top of the resident's drinking cup with the same hand and assisted with a drink.
The CNA then turned to Resident 94 and palmed the top of that resident's bowl. She obtained a spoonful of food, brought it up to her lips, and blew on it to cool it before placing it into the resident's mouth. She told Resident 75 that his food "was not hot because she had blown on it" before offering him a bite.
The staff member then picked up Resident 94's unused fork, reached across the table, and used it to move food around on Resident 76's plate before setting the fork back in front of Resident 94. Throughout the entire observation, the CNA did not perform hand hygiene.
When she later obtained a clean cup from the kitchenette, she put her finger inside the rim while pouring milk. She then picked up the previously used fork from in front of Resident 94 and used it to offer Resident 75 his dessert.
This cascade of improper food handling and utensil sharing between residents contradicted basic food safety principles. Another staff member interviewed about proper protocols confirmed that "plates, bowls, and cups were handled from the bottom and the tops of bowls and cups were not touched" and that "utensils were not shared among residents."
The Infection Preventionist also confirmed that food "was not to have been blown on to cool it off" and that "tableware was to be handled from the underside and the top rim or lip area of cups and bowls were not to be touched."
Medical Significance of Documented Failures
The residents affected by these violations included individuals with significant underlying health conditions that placed them at heightened risk for complications from respiratory infections. Resident 29, for example, had chronic obstructive pulmonary disease, dependence on supplemental oxygen, pneumonia, and acute respiratory failure with hypoxia. Resident 147 had chronic obstructive pulmonary disease and bronchitis. Resident 369 had morbid obesity and cirrhosis of the liver.
Influenza and other respiratory infections can be particularly dangerous for elderly nursing home residents, especially those with pre-existing respiratory conditions or compromised immune systems. When infection control protocols break down, outbreaks can spread rapidly through a facility population that has limited ability to protect themselves.
The CDC guidelines that the facility claimed to follow exist specifically because droplet precautions form a critical barrier against the transmission of respiratory pathogens. Eye protection is required because the mucous membranes of the eyes provide a direct entry point for infectious droplets.
Facility Policy Versus Practice
The inspection revealed a disconnect between the facility's written policies and actual staff practices. The facility's policy on transmission-based precautions, dated 2001, clearly stated that "gloves, gown and goggles are worn if there is risk of spraying respiratory secretions" for droplet precautions.
The Infection Preventionist confirmed during interviews that staff were required to wear "a surgical face mask and a face shield or goggles for residents requiring droplet precautions." However, multiple staff members indicated during the inspection that they had been trained they did not need face shields for specific residents on droplet precautions.
This inconsistency between policy, training, and practice suggests a breakdown in the facility's infection control program implementation that extended beyond individual staff errors.
Additional Issues Identified
The inspection documented that the infection control failures were systematic rather than isolated incidents:
- Multiple staff members across different departments, including CNAs, qualified medication aides, and dietary staff, demonstrated the same gaps in infection control practices - Staff expressed confusion about requirements, with some believing eye protection was optional while facility policy and the Infection Preventionist confirmed it was mandatory - Hand hygiene failures occurred repeatedly both in isolation rooms and during dining assistance - Proper food handling protocols were not followed during meal assistance, with staff sharing utensils between residents and blowing on food to cool it
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peabody Retirement Community from 2025-04-09 including all violations, facility responses, and corrective action plans.
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