ARLINGTON, VA - State health inspectors identified serious infection control violations at Cherrydale Health and Rehabilitation Center that posed immediate jeopardy to resident safety, including improper disinfection of blood glucose monitoring equipment and failure to follow basic hygiene protocols during catheter care. The April 2025 inspection revealed systemic breakdowns in fundamental healthcare practices that exposed vulnerable residents to preventable infections.
Critical Blood Glucose Monitor Contamination Risk
The most serious finding involved the facility's failure to properly disinfect glucometers between resident uses, creating a direct pathway for bloodborne pathogen transmission. During the inspection, staff members were observed using the same blood glucose monitoring devices on multiple residents without following proper disinfection protocols between uses.
Blood glucose monitors come into direct contact with blood during testing, making proper disinfection between uses essential for preventing cross-contamination. When these devices are not properly cleaned with germicidal wipes between residents, they can transmit serious infections including hepatitis B, hepatitis C, and HIV. The risk is particularly elevated in nursing home settings where many residents have compromised immune systems due to age, diabetes, and other chronic conditions.
The violation was severe enough that inspectors declared an immediate jeopardy situation - the highest level of regulatory action that indicates residents face immediate risk of serious harm or death. The facility was required to implement an emergency correction plan that included retraining all nursing staff on proper glucometer disinfection procedures and establishing a monitoring system to ensure ongoing compliance.
Following intensive corrective actions, including interviews with all nurses providing direct care across four units and verification that germicidal wipes were available on all medication carts, inspectors determined the immediate jeopardy was removed on April 23, 2025. However, the fact that such a fundamental infection control practice was not being followed raises serious questions about the facility's overall quality management systems.
Catheter Care Violations Expose Residents to Urinary Tract Infections
Inspectors documented multiple violations related to urinary catheter care that significantly increased residents' risk of developing catheter-associated urinary tract infections (CAUTIs). These infections represent one of the most common healthcare-associated infections in nursing homes and can lead to sepsis, kidney damage, and death in elderly residents.
During observation of catheter care for a resident on Enhanced Barrier Precautions, a certified nursing assistant was observed failing to wear required personal protective equipment including gown and gloves. The staff member was also observed picking up a washcloth that had fallen on the floor with a gloved hand, then using those same contaminated gloves to handle clean supplies and provide direct resident care.
Most concerning was the observation that the CNA performed catheter cleaning without using soap in the water and failed to change gloves when moving from contaminated to clean areas. When interviewed, the CNA admitted: "I did not put soap into the water because I thought it was just a demonstration, so I just left it out." This statement reveals a fundamental misunderstanding of infection control principles and suggests that proper technique may not be consistently followed even when staff know they are being observed.
The facility's own policies clearly required staff to wear full PPE (gown, gloves, and mask) when providing care to residents on Enhanced Barrier Precautions, particularly during high-contact activities like catheter care. The policies also mandated changing gloves when moving from dirty to clean areas and using proper cleansing techniques.
Repeated Failures in Catheter Bag Positioning
Inspectors identified a pattern of improper catheter bag positioning that violated basic infection prevention standards. One resident's urine collection bag was observed resting on the floor on three separate occasions over a three-day period, despite facility policies requiring bags to be positioned below bladder level but off the floor.
When catheter bags touch the floor, they can pick up bacteria and other pathogens that can travel up the drainage tubing and into the bladder, causing serious infections. This is particularly dangerous for residents with neurogenic bladders or urinary retention who depend on catheters for urinary drainage and may not be able to communicate symptoms of infection effectively.
The unit manager confirmed that catheter bags "should be positioned below the bladder and without contact with the floor for infection prevention," yet this basic standard was repeatedly violated. The persistence of this problem across multiple days and observations suggests inadequate monitoring and supervision of direct care practices.
Vaccination Documentation Failures Leave Residents Unprotected
The inspection revealed widespread failures in documenting and ensuring appropriate vaccination status for residents at high risk for respiratory infections. Four residents with diabetes - a condition that significantly increases vulnerability to influenza, pneumonia, and COVID-19 complications - had no documentation of receiving these critical vaccines or formal refusals.
Diabetes impairs immune function and increases the severity of respiratory infections. The CDC strongly recommends annual influenza vaccination, appropriate pneumococcal vaccination, and up-to-date COVID-19 vaccination for all adults with diabetes. Without proper documentation, there is no way to verify whether these residents received potentially life-saving vaccines or made informed decisions to refuse them.
The facility's Infection Preventionist admitted during the inspection: "We do not have any documented refusals or administrations for these residents." This represents a fundamental breakdown in preventive care management and leaves residents unnecessarily vulnerable to vaccine-preventable diseases that cause thousands of nursing home deaths annually.
Additional Issues Identified
Beyond the major violations, inspectors documented concerning safety issues including a bathroom grab bar that was pulling away from the wall in a resident's room. The resident, who was cognitively intact and required assistance with walking due to chronic kidney failure and peripheral vascular disease, reported being worried about the bar being "pulled off the wall when trying to get off the toilet." Despite the resident reporting this safety hazard, no work order had been placed for repairs.
The maintenance director acknowledged that the poorly secured grab bar "was not safe to be used," yet the facility's system for identifying and addressing safety hazards had failed to detect or correct this problem. Falls in nursing homes frequently result in hip fractures, head injuries, and other serious complications that can be fatal for elderly residents.
Industry Standards and Medical Implications
The violations documented at Cherrydale Health and Rehabilitation Center represent failures of basic healthcare practices that should be second nature in any medical setting. Proper hand hygiene, appropriate use of personal protective equipment, and careful handling of medical devices that come into contact with blood or body fluids are foundational elements of infection control that healthcare workers learn in their earliest training.
The consequences of these failures extend beyond individual infections. When infection control breaks down in a nursing home, it can lead to facility-wide outbreaks that overwhelm staff resources, require costly interventions, and most importantly, cause preventable suffering and death among residents who trusted the facility with their care.
The immediate jeopardy designation and subsequent corrective actions highlight the seriousness of these violations. However, the fact that such fundamental practices were not being followed raises questions about the effectiveness of the facility's training programs, supervision structures, and quality assurance systems. Proper infection control requires not just knowledge but consistent application of that knowledge in every resident interaction, every shift, every day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cherrydale Health and Rehabilitation Center from 2025-04-24 including all violations, facility responses, and corrective action plans.
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