One resident required intensive care unit admission after developing vomiting, diarrhea, weakness and confusion on April 9. Resident 107 was "unable to speak coherently" when sent to the emergency room and was diagnosed with pneumonia, continuing to experience diarrhea throughout her hospitalization.
Three residents tested positive for norovirus between April 6 and April 14. After those confirmations, all residents with gastrointestinal symptoms were assumed to have the virus and tracked for infection control purposes.
Federal inspectors observed multiple infection control violations during their April 22-25 visit. Two certified nursing aides changing an incontinent resident kept the same soiled gloves throughout the entire process, then removed them without washing their hands. With their contaminated hands, they touched the resident's wheelchair, positioning pillow, water cup and drinking straw, plus door handles and medical equipment.
When questioned, neither aide realized they had missed opportunities for proper hygiene. One asked the inspector, "how soon she should have performed hand hygiene after removing her gloves as she explained she came out here [the hallway] to do that, is that not soon enough?"
The inspector explained that touching a resident's water cup and straw with contaminated hands "potentially increased the risk of spreading infection." The aide "agreed she had done that and promptly walked away from the conversation."
Staff repeatedly ignored contact precaution requirements for infected residents. Inspectors watched two aides care for resident 33, who had a contact precautions sign on her door requiring gowns and gloves. Neither aide wore any protective equipment while providing care.
One aide wheeled resident 33 down the hallway while holding a bag of trash with the same hand touching the wheelchair handle. The medical lift used for the resident was never cleaned after use, despite facility policy requiring cleaning after each resident.
When questioned, one aide said she "did not know how to tell which resident in that room was on contact precautions," despite the posted signage. She knew contact precautions required gowns and gloves but said, "I don't know, that's what I was trained to do, to just follow the other CNA."
The aide also contracted the gastrointestinal illness spreading through the facility.
During meal service, inspectors observed additional hygiene failures. One aide touched her hair braids, then continued helping residents eat without washing her hands, touching straws, silverware, condiments and napkins. Another aide coughed into her hand, failed to sanitize, then delivered meal trays to nine residents.
A third aide assisted residents with eating after one resident coughed, offering no hand sanitizer or wipes to the resident before continuing to help others eat.
Resident 33, who was cognitively intact, confirmed to inspectors that "staff did not put on gowns when they helped her with personal cares" during her illness. She experienced diarrhea from April 8 through April 11.
The facility's own quality improvement data showed persistent infection control problems. Hand hygiene compliance remained at 90 percent from January through April 2025, falling short of the facility's stated 95 percent benchmark. Personal protective equipment compliance was even worse at 85 percent for three months, improving only to 90 percent in April.
Meeting notes showed identical responses month after month: "ICP continue to educate staff [of] the importance of hand [hygiene]" and "ICP continue to educate staff [of] the importance of the signs on the doors and wearing the correct PPE." The facility attempted no other interventions beyond repeated education.
Administrator A acknowledged during the inspection that their plan of correction "did not include actions beyond educating staff" and they "had not tried any other documented methods to increase hand hygiene and PPE compliance."
The facility's infection preventionist, registered nurse G, confirmed the April norovirus outbreak was facility-wide, affecting both residents and staff. Director of nursing services B, who started April 7, said she noted "concerns in infection control such as hand hygiene" immediately upon beginning her position.
Both nursing leaders "appeared disappointed when they were informed about the above observations" and "expected staff to have followed the provider's policies on hand hygiene, glove use, and contact precautions."
The facility's own policies emphasized that "hand hygiene [is] the primary means to prevent the spread of infections" and required staff to wear gloves and gowns when caring for residents on contact precautions.
Anonymous complaints to state health officials in mid-April reported concerns about the "severe outbreak of norovirus" and fears that the facility "was not monitoring hand washing, sanitation, [and] dishwashing." One complainant was "fearful for their family member that resided at the facility."
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.