The patient, who has malignant tumors in her right breast and bone along with dangerously low blood platelet counts, told inspectors at The Earlwood that she felt frustrated after having to cancel her Friday appointment. "Her laboratory tests were not drawn," she explained during an April 24 interview.
The Social Services designee admitted she told a registered nurse that the patient needed lab work for her upcoming appointment, but the nurse left early that day. She never followed up to ensure the tests were completed.
"She did not follow up to ensure it was done," the inspection report stated. The social services worker told inspectors she would develop a system to prevent delays in patient care, as she had to reschedule the medical appointment.
The breakdown occurred despite the facility's job description requiring social workers to "assist in obtaining resources from community social, health, and welfare agencies to meet the needs of the resident."
But laboratory failures weren't the only safety problem inspectors found during their April complaint investigation.
Staff repeatedly skipped basic hand hygiene between patient rooms, creating potential for dangerous cross-contamination throughout the facility. A licensed vocational nurse was observed entering and leaving a patient's room to change an oxygen machine without washing her hands or using sanitizer.
When questioned, the nurse admitted she forgot to perform hand hygiene despite knowing the requirements. "She was supposed to perform hand hygiene before entering a resident room and prior to exiting a resident room and should have done so but forgot," she told inspectors.
The hand sanitizer dispenser in that patient's room was empty.
A certified nursing assistant made the same mistake, failing to sanitize before entering and leaving another patient's room. She acknowledged that hand hygiene was important to prevent infection spread but said the sanitizer dispenser was empty and she should have gone to the nurses' station to wash her hands.
During the initial facility tour, inspectors found that two of four patient rooms had no hand sanitizing gel in their dispensers. No hand sanitizer dispensers were mounted on hallway walls.
The Infection Prevention Nurse explained that some rooms lacked sanitizer due to supply back-orders, and hallway dispensers were missing because of ongoing renovations. She said staff had been educated to wash hands at nursing stations when room dispensers were empty.
The Director of Nursing called hand hygiene "the most important way to prevent cross contamination and the spread of infection in the facility." She emphasized that staff should wash hands before and after patient care and when entering and leaving rooms because failures "can affect the safety of the residents and the staff."
The facility's own policy, dated September 2023, states that hand hygiene is "the primary means to prevent the spread of infection" and that "hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance."
The infection control problems extended to staffing qualifications. The facility's Infection Prevention Nurse lacked proper certification for her role, having completed only a basic CDC training course that didn't specify hours of instruction.
The nurse, a new graduate who started at the facility in November 2024 and became the infection preventionist in February 2025, told inspectors she was "unable to locate the correct Infection Preventionist certificate." She said the CDC training was what she was told she needed.
The Director of Nursing said she was unaware the infection prevention nurse had incorrect certification. She called the role "crucial in maintaining infection control and prevention in the facility" and said it was important to have a qualified full-time infection prevention nurse "for the safety of the residents and staff."
The facility's job description for infection preventionists requires planning, developing, implementing and overseeing the infection prevention program "in accordance with current regulations and guidelines." It specifies a minimum of two years clinical experience in hospitals, nursing facilities or related healthcare settings.
The cancer patient who missed her oncologist appointment requires moderate assistance with toileting and dressing but has intact cognitive abilities, according to her March assessment. Her frustration over the canceled appointment highlights how administrative failures can directly impact patients fighting serious illnesses.
The inspection found these violations placed residents at risk for delayed medical care and potential infection spread throughout the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Earlwood from 2025-04-24 including all violations, facility responses, and corrective action plans.