Federal inspectors documented systematic failures in hand hygiene and protective equipment use during the outbreak that affected nearly half the facility's 104 residents. Three residents tested positive for the highly contagious virus, while 42 others developed gastrointestinal symptoms between April 6 and April 14.
Staff contaminated equipment, touched residents' food and water with unwashed hands, and failed to wear required gowns and gloves when caring for infected patients. The violations occurred despite the facility's own policies stating that hand hygiene was "the primary means to prevent the spread of infections."
The outbreak began April 8, one day after the facility's new director of nursing started her position. Resident 107 became so ill with vomiting, diarrhea, weakness and confusion that she was hospitalized in intensive care with pneumonia. She continued experiencing diarrhea throughout her hospital stay.
Anonymous complaints to state health officials expressed fear for family members at the facility and concerns about inadequate sanitation and dishwashing monitoring.
Staff Contaminated Resident Care Items
On April 22, inspectors observed certified nurse aide M and certified medication aide BB providing personal care to an incontinent resident. After cleaning the resident and removing soiled gloves, both aides failed to wash their hands before touching the resident's wheelchair, positioning pillow, water cup and drinking straw.
CNA M held the straw between her fingers and helped the resident drink water with her contaminated hands. Neither aide performed hand hygiene after completing care.
When questioned about the violations, CNA M asked "how soon she should have performed hand hygiene after removing her gloves" and wondered if doing it in the hallway was "soon enough." After inspectors explained she had contaminated the resident's water cup, she "promptly walked away from the conversation."
The same day, inspectors observed staff violating contact precautions for resident 33, who had been placed in isolation after developing diarrhea and vomiting. CNAs L and M entered her room without wearing required gowns and gloves, then transported her in a wheelchair while holding trash and touching equipment.
CNA L admitted she "did not know how to tell which resident in that room was on contact precautions" despite posted signs and available protective equipment. She said she was "trained to just follow the other CNA" and acknowledged catching the gastrointestinal illness herself.
Dining Room Violations Spread Contamination
During meal service, staff contaminated food and beverages while assisting multiple residents. CNA/CMA BB touched her hair braids and continued helping two residents eat without washing her hands, handling their silverware, condiments and napkins.
On the memory care unit, CNA HH coughed into her hand, served meal trays without sanitizing, and removed a contaminated rehabilitation cone from a resident's mouth before continuing to serve other residents without hand hygiene.
CNA GG assisted residents with eating after they coughed, moving between tables without sanitizing her hands between residents.
Quality Improvement Program Failed
The facility's quality assurance program identified infection control as a performance measure but failed to implement effective improvements. Monthly compliance rates for hand hygiene remained at 90 percent from January through April 2025, consistently below the facility's 95 percent benchmark.
Personal protective equipment compliance was even worse, measuring 85 percent for three consecutive months before improving to 90 percent in April.
Administrator A acknowledged during interviews that their plan of correction included only staff education, with no other documented methods attempted to improve compliance. Meeting notes from January, February and March contained identical language about continuing to "educate staff of the importance of hand hygiene."
Flying Ants Bit Resident for Weeks
While dealing with the norovirus outbreak, the facility struggled with a separate pest control failure affecting resident 91. The 91-year-old man complained of flying ants in his room daily, killing "30 to 40 of the flying ants every day" for several weeks.
Every morning, his bedside table was "covered with them and four to five of the flying ants were in his bed." The resident showed inspectors "several small red marks on his mid back" from ant bites, saying "I can feel them when they bite, they grab your attention."
Maintenance supervisor W confirmed the problem began April 11 when a work order was entered into their system. Despite deep cleaning, ant bait placement, and outside spraying, the infestation continued.
Administrator A said their pest control company visited the room multiple times but eventually told him "they could not do anything more regarding the flying ants."
On April 24, after inspectors documented the ongoing problem, staff finally moved resident 91 to another room. That afternoon, inspectors found two live flying ants on the window screen of his evacuated room, along with sticky traps and ant bait containers.
In his new room, resident 91 reported sleeping ten hours without seeing any bugs and said he was "in a good mood."
Regulatory Response
The facility's infection control policies required staff to wear gowns and gloves when providing care to residents on contact precautions and to perform hand hygiene to prevent infection transmission. Their pest control policy promised "an environment free of pests" with prompt reporting and treatment.
Director of nursing services B, who started April 7, said she noted "concerns in infection control such as hand hygiene" during her brief tenure. She and the division director of clinical services "appeared disappointed when they were informed about the above observations" and expected staff to follow facility policies.
The facility maintained monthly pest control contracts targeting ants, spiders and roaches, with documented service visits January 8, February 3, March 5 and April 1. An additional treatment occurred March 21, though the facility lacked documentation of that visit.
Resident 91 had been offered room changes multiple times during the three-week ant infestation but initially declined, preferring his current accommodations despite the daily bites and sleep disruption.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Firesteel Healthcare Center from 2025-04-25 including all violations, facility responses, and corrective action plans.