SMYRNA, DE – Federal inspectors identified multiple infection control breakdowns and a discharge error involving an intravenous catheter during an April 2025 survey at Pinnacle Rehabilitation & Health Center, a skilled nursing facility in Kent County.
Resident Discharged with PICC Line Still in Place
One of the most significant findings involved a resident who was sent home with a peripherally inserted central catheter (PICC line) that staff had documented would be removed before discharge.
According to the inspection report, the resident was admitted in September 2024 with heart failure and chronic obstructive pulmonary disease. On October 2, 2024, a nurse practitioner entered an order to discontinue the PICC line in the resident's right arm. The following day, during a discharge planning conference attended by a registered nurse and the resident's daughter, documentation stated that "PICC will be pulled by nursing."
However, when the resident arrived home on October 5, 2024, the catheter remained in place. The resident's daughter told investigators during an April 2025 telephone interview: "When my mom arrived home after discharge from Evergreen, her PICC line was still in. It was supposed to be taken out at Evergreen prior to discharge."
PICC lines are central venous catheters that provide direct access to the bloodstream and are typically used for administering medications, fluids, or nutrition. When left in place unnecessarily, these devices carry substantial infection risks. Central line-associated bloodstream infections (CLABSIs) are among the most serious healthcare-acquired infections, with mortality rates ranging from 12% to 25% in hospitalized patients. Even after discharge, an unneeded PICC line creates an ongoing entry point for bacteria and requires specialized removal procedures that may not be readily available in home or hospice settings.
The failure also represents a breakdown in the discharge planning process. Standard nursing protocols require verification that all discharge orders have been completed before a patient leaves the facility. This includes confirming that medical devices scheduled for removal have been addressed and that the patient's current status matches the discharge documentation.
Infection Control Protocols Not Followed
Inspectors documented multiple failures in the facility's infection prevention and control program, including delayed implementation of required precautions and improper handling of contaminated materials.
MRSA Pneumonia Case Without Proper Precautions
One resident was discharged from a hospital in October 2024 with a diagnosis of MRSA pneumonia and was prescribed the antibiotic linezolid for 20 days of treatment. The hospital discharge summary specifically noted the diagnosis was "due to positive MRSA swab." Despite this documentation, the facility did not implement contact precautions for the resident during the entire course of antibiotic treatment.
MRSA (methicillin-resistant Staphylococcus aureus) is a multidrug-resistant organism that spreads through direct contact. CDC guidelines and the facility's own infection control policy require contact precautions for residents with active MRSA infections. These precautions include gown and glove use during patient contact to prevent transmission to other residents and healthcare workers.
Eight-Month Delay in Barrier Precautions
Another resident had a documented history of ESBL (extended-spectrum beta-lactamase producing organisms) in urine cultures and had a colostomy. CMS mandated Enhanced Barrier Precautions (EBP) for residents with indwelling devices and MDRO histories effective April 1, 2024. However, the facility did not initiate EBP for this resident until November 22, 2024—eight months after the requirement took effect.
The Director of Nursing confirmed during a subsequent interview that the resident had maintained a colostomy throughout his stay at the facility, meaning the enhanced precautions should have been implemented immediately when the new guidelines became effective.
Contaminated Materials Spread Between Rooms
Inspectors observed a certified nursing assistant leaving a room with EBP signage while wearing disposable gloves. The aide picked up a trash bag containing dirty briefs and gloves that had been left on the floor, then proceeded to another EBP room and entered while still wearing the same contaminated gloves.
When the Director of Nursing observed the situation, she stated: "No this should not be—it should go directly to the biohazard room." The DON then educated the aide on proper glove use, hand hygiene, and that contaminated materials should not travel from room to room.
Later that morning, inspectors found additional trash bags with dirty linens and briefs sitting on the floor inside an EBP room. The Unit Manager acknowledged the finding and confirmed that "trash bags being left on the floor is an infection control concern."
These practices violate fundamental infection control principles. Contaminated materials serve as vectors for pathogen transmission, and carrying them between patient rooms—particularly rooms with isolation precautions—significantly increases the risk of spreading drug-resistant organisms throughout the facility.
Fall Prevention Interventions Not Implemented
A high-risk resident who had previously broken a leg during a fall at the facility did not receive the fall prevention measures specified in the care plan.
The resident was originally admitted in June 2024 and required extensive assistance with most activities of daily living. After returning from the hospital in September 2024 following treatment for a right leg fracture from a facility fall, a revised care plan dated October 2, 2024, specified that fall mats should be placed at the bedside when the resident was in bed.
A fall risk assessment conducted on October 3, 2024, scored the resident at 17, indicating high fall risk. Despite this documentation, inspectors observed no fall mats at the bedside on three separate occasions:
- April 8, 2025, at 7:46 AM - April 11, 2025, at 2:27 PM - April 15, 2025, at 10:25 AM
Two certified nursing assistants confirmed during an interview on April 15 that no fall mats were present in the room. The Director of Nursing acknowledged that the intervention was listed on the task list and confirmed that fall mats should have been in place, stating "the issue would be addressed immediately."
Fall mats provide cushioning that can reduce injury severity if a resident falls from bed. For high-risk residents with established fall histories and mobility limitations, consistent implementation of documented interventions is essential. The failure to place fall mats on multiple occasions over a week-long period suggests a systemic gap between care planning and actual care delivery.
Antibiotic Stewardship Monitoring Gaps
The facility's antibiotic stewardship program failed to track multiple antibiotic courses prescribed to residents, according to the inspection findings.
One resident was treated with two antibiotics—cefpodoxime and metronidazole—following a surgical procedure in December 2024. Neither medication appeared on the facility's infection control line listing for that month. The resident's hospital discharge summary documented that cefpodoxime was prescribed post-operatively after removal of a necrotic mass.
A second resident received vancomycin for C. difficile infection in December 2024 and Bactrim for a urinary tract infection in February 2025. Neither the infections nor the antibiotic courses appeared on the facility's monthly infection control line listings.
The facility's Infection Preventionist confirmed during an interview that "the monthly infection control line listing was the method that the facility used to track infections and antibiotic usage in the facility."
Antibiotic stewardship programs are designed to optimize antibiotic use while reducing adverse events and the development of drug-resistant organisms. Accurate tracking of antibiotic prescriptions is fundamental to identifying patterns, evaluating appropriateness of therapy, and monitoring for potential complications such as C. difficile infections, which can be triggered by antibiotic use.
Additional Issues Identified
Beyond the major violations, inspectors documented several other deficiencies:
Medication Labeling: Ten liquid medications across three medication carts were found opened but undated. Proper labeling with open dates is essential for tracking medication expiration and ensuring potency.
Food Safety Violations: Multiple food handling issues were observed, including undated and unlabeled items in a unit refrigerator, a dietary aide touching her nose and face mask before handling bread without changing gloves, plates and dessert cups with food debris in clean storage areas, meat stored above vegetables while thawing, and visible dust on kitchen ventilation fans.
Dietary Orders Not Followed: A resident with a physician's order for large portions was observed receiving regular-sized portions on two consecutive days. Staff confirmed the portions served did not match the dietary order.
Vaccination Assessment Errors: One resident received a pneumococcal vaccine from the facility despite having already received the same vaccine five months earlier at another location. Another resident with documented cognitive impairment signed vaccination consent forms without involvement of the designated power of attorney.
All findings were reviewed with the facility's Nursing Home Administrator and Director of Nursing on April 17, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pinnacle Rehabilitation & Health Center from 2025-04-17 including all violations, facility responses, and corrective action plans.
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