ANAHEIM, CA - A recent state inspection of Anaheim Healthcare Center identified widespread infection control failures and medication administration problems that put residents at risk for serious infections and preventable illnesses. The April 14, 2025 survey documented violations ranging from improper use of personal protective equipment in COVID-19 isolation rooms to failures in administering critical vaccines.
Staff Failed to Follow COVID-19 Isolation Protocols
The most concerning violations involved multiple instances of staff entering and exiting COVID-19 positive rooms without following proper infection control procedures. Inspectors observed a Licensed Vocational Nurse (LVN) entering a COVID-19 positive room marked with contact/droplet isolation signs without performing hand hygiene. The room had clear signage and a PPE cart stationed at the doorway, yet the nurse bypassed these safety measures entirely.
In another incident, a Certified Nursing Assistant left a COVID-19 isolation room while still wearing contaminated gloves and without a gown. The aide then placed potentially contaminated tray covers directly onto a clean meal cart containing three clean meal trays, creating a significant cross-contamination risk. The facility's own policies required staff to wear N95 masks, gowns, gloves, and eye protection when entering COVID-19 positive rooms.
A registered nurse was observed standing at the entrance of a COVID-19 positive room, speaking with residents inside without wearing the required N95 mask. The room displayed clear signage stating "Red Room - Please Keep Door Closed at All Times" and listed all required PPE. When interviewed, the nurse acknowledged she "should have worn her N95 mask when talking to the COVID-19 positive residents at the doorway."
These breaches are particularly dangerous because COVID-19 spreads primarily through respiratory droplets and aerosols. When healthcare workers fail to use proper PPE, they become vectors for transmission, potentially carrying the virus from infected residents to vulnerable populations throughout the facility. The elderly and those with underlying health conditions face significantly higher risks of severe illness, hospitalization, and death from COVID-19.
Critical Gaps in Vaccine Administration Left Residents Unprotected
The inspection revealed systematic failures in the facility's immunization program, with multiple residents not receiving vaccines despite having documented consent. One resident's responsible party had provided written consent for COVID-19 vaccination on September 20, 2024, yet more than six months later, the vaccine had never been administered. The facility's immunization records showed no evidence the vaccine was given after consent was obtained.
Similarly, documentation showed a pneumococcal vaccine was refused by another resident, but the refusal form was undated, and there was no record of when the vaccine was offered or any subsequent attempts to provide it. The facility's own policies required that vaccines be administered unless medically contraindicated, already given, or refused with proper documentation.
Pneumococcal disease can cause severe infections including pneumonia, meningitis, and bloodstream infections, with mortality rates of 5-7% even with treatment. In nursing home populations, these rates can be significantly higher. The influenza vaccine is equally critical, as flu outbreaks in long-term care facilities can spread rapidly and cause severe complications including secondary bacterial pneumonia, worsening of chronic medical conditions, and death.
Improper Medication Administration Through Feeding Tubes
Inspectors documented a particularly concerning incident where an LVN administered medications through a gastrostomy tube (GT) without wearing the required protective equipment. The resident was on Enhanced Barrier Precautions due to having multiple indwelling medical devices, which increase infection risk. The nurse checked tube placement, measured residual stomach contents, and administered medications all without wearing a gown as required by facility policy.
Gastrostomy tubes provide direct access to the stomach and bypass the body's natural defense mechanisms. When healthcare workers fail to use proper PPE during GT medication administration, they risk introducing bacteria directly into the digestive system. This can lead to serious complications including peritonitis, systemic infections, and sepsis. The nurse also failed to sanitize the stethoscope after using it to check tube placement, potentially spreading pathogens between residents.
Contamination Risks Throughout the Facility
The inspection revealed numerous instances of improper storage and handling of medical equipment and meal service items. Urinals containing urine were found placed next to residents' meal trays and drinking water. In one room, a urinal filled with urine sat on a bedside table directly beside a breakfast tray. In a shared bathroom, an unlabeled urinal was hanging on a waste bin, creating confusion about ownership and increasing cross-contamination risks.
Staff also placed a finished meal tray on top of a PPE cart containing clean face shields and gowns outside an isolation room. Personal items and trash were discovered in the clean linen sorting area, including a container of personal lotion and crumpled paper. These violations demonstrate a fundamental breakdown in basic infection control practices.
Cross-contamination between clean and dirty items is a primary pathway for infection spread in healthcare facilities. When urinals are placed near food and water, fecal-oral transmission becomes possible. Contaminated PPE carts can spread pathogens to anyone who subsequently uses that equipment, potentially affecting multiple residents and staff members.
Additional Issues Identified
The facility's antibiotic stewardship program lacked clear guidelines for determining true infections and failed to specify treatment duration for long-term antibiotics. One resident receiving rifaximin for hepatic encephalopathy had no documented duration for the antibiotic therapy, increasing risks of antibiotic resistance development.
The infection control surveillance system failed to include residents with signs and symptoms of infection, preventing early detection and intervention. Blood glucose monitoring equipment lacked proper documentation of serial numbers on quality control records, potentially affecting the accuracy of diabetic care.
Staff were observed failing to follow Enhanced Barrier Precautions for residents with indwelling medical devices including urinary catheters and feeding tubes. The facility's infection screening evaluation component lacked criteria for determining true infections and had no option to indicate when no infection criteria were met.
Systemic Infection Control Failures
These violations represent systemic breakdowns in fundamental infection control practices. The facility demonstrated repeated failures to implement its own policies and procedures, despite having detailed protocols for COVID-19 prevention, vaccination administration, and infection control. The pattern of violations suggests inadequate staff training, insufficient supervision, and a lack of accountability for following established safety protocols.
In long-term care settings, infection control is not merely a regulatory requirement but a critical component of resident safety. Elderly residents often have weakened immune systems, multiple chronic conditions, and are living in close proximity to one another. A single breach in infection control can trigger facility-wide outbreaks with devastating consequences. The COVID-19 pandemic has demonstrated how quickly respiratory infections can spread through nursing homes when proper precautions are not followed.
The facility's Director of Nursing acknowledged the findings during the inspection, confirming that staff should have followed proper PPE protocols and infection control measures. The pattern of violations across multiple departments and shifts indicates these were not isolated incidents but rather systemic failures requiring comprehensive corrective action.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Anaheim Healthcare Center, LLC from 2025-04-14 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.