ROSLYN, SD - Federal inspectors documented serious infection control violations at Strand-Kjorsvig Community Rest Home in May 2025, finding staff failed to follow protective barrier protocols and lacked proper oversight of antibiotic use, potentially exposing vulnerable residents to preventable infections.
Breakdown in Enhanced Barrier Precautions
The most concerning violations involved the facility's failure to implement enhanced barrier precautions (EBP) - critical infection control measures designed to protect residents with wounds, medical devices, or increased infection risk. Inspectors found systemic failures in following these protocols for residents requiring specialized protection.
Two residents specifically placed on EBP experienced inadequate protection. Resident 79, who had returned from the hospital with surgical staples and an incision requiring clean, dry care, had an EBP sign posted on her door. However, no personal protective equipment was available at or near her room, despite facility policy requiring staff to wear gowns and gloves for high-contact activities including wound care, bathing, dressing changes, and transfers.
The resident herself was unaware why the sign was posted, and staff interviews revealed confusion about the requirements. One certified nursing assistant stated she was "unsure why the EBP sign was on the resident's door" and indicated gowns were kept in the resident's dresser drawer rather than being readily accessible for immediate use.
More troubling was the case of Resident 25, a cognitively intact individual receiving therapy services for a right ankle fracture with an open surgical wound requiring daily antimicrobial dressing changes. Despite having EBP protocols in place, the resident reported that "staff wore gloves when they changed his dressing and assisted him with cares, but they did not wear a gown." He confirmed no gowns were stored near his room entrance for staff use.
Inspectors directly observed violations when physical therapy staff provided treatment to Resident 25 in the therapy area without any protective equipment. A physical therapy assistant placed a gait belt on the resident, assisted him to standing, and provided continuous contact during walking exercises - all high-contact activities specifically mentioned in the facility's EBP policy - while wearing no gloves or gown.
Medical Significance of Barrier Precaution Failures
Enhanced barrier precautions serve as a crucial defense against multidrug-resistant organisms (MDROs) in nursing home settings. These protocols are particularly critical for residents with open wounds, surgical sites, or indwelling medical devices, as these conditions create entry points for dangerous bacteria.
Surgical wounds, like those affecting both residents in this case, are especially vulnerable to infection during the healing process. The antimicrobial cream prescribed for Resident 25's ankle wound indicates the surgical site was already considered at risk for bacterial contamination. Without proper gown and glove use during wound care and transfers, staff could inadvertently introduce bacteria from their clothing or hands directly into the wound site.
The facility's own policy recognized these risks, explicitly stating that EBP should be followed "when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility." The policy was designed to prevent transmission not only in residents' rooms but throughout all areas where high-contact care occurs.
When staff fail to follow these protocols, they create pathways for bacteria to spread between residents and potentially introduce antibiotic-resistant infections that are much more difficult to treat. This is particularly dangerous in nursing home populations, where residents often have compromised immune systems and multiple comorbidities that make them more susceptible to serious complications from infections.
Inadequate Antibiotic Stewardship Program
Compounding the infection control problems, inspectors found the facility's antibiotic stewardship program was essentially non-functional. The director of nursing, who served as the infection preventionist, admitted the facility was "noncompliant almost always" with required protocols for documenting symptoms before requesting antibiotic treatment.
The director of nursing revealed a concerning practice of bypassing established infection criteria. She stated that staff would request urinalysis orders from physicians without documenting the required symptoms because she felt "they know when a resident had a change in their health status." This approach directly contradicted the facility's written policy requiring completion of symptom assessment forms based on established medical criteria before contacting physicians about potential infections.
This lack of systematic symptom documentation creates multiple problems. Without proper assessment protocols, staff may miss early signs of serious infections or, conversely, may request unnecessary antibiotic treatments that contribute to resistance development. The medical director had reportedly refused some urinalysis requests, stating residents needed more documented symptoms - highlighting the tension between the facility's informal practices and medical standards.
Systemic Program Failures
The antibiotic stewardship program violations extended far beyond individual cases. The director of nursing acknowledged she had failed to implement multiple required components of the facility's own policy, including:
- No annual summary of antibiotic use despite policy requirements for yearly reporting to the quality committee - No antibiotic stewardship meetings as specified in facility protocols - No random audits of antibiotic prescriptions for appropriateness - No tracking of outcome measures related to antibiotic use - No antibiogram analysis (bacterial resistance patterns) to guide prescribing decisions - No annual feedback to physicians regarding their antibiotic prescribing practices
Perhaps most concerning, the director of nursing was unaware that the facility's urinary tract infection rates for long-stay residents exceeded both state and national averages - a critical quality indicator that should have triggered immediate program improvements.
The only antibiotic monitoring consisted of reviewing monthly pharmacy reports that listed medications dispensed but contained no information about diagnoses, treatment appropriateness, or clinical outcomes. This superficial approach provided no meaningful oversight of antibiotic use patterns or effectiveness.
Incomplete Staff Training and Oversight
Inspectors also found that the facility's infection preventionist - the person responsible for overseeing all infection control programs - had not completed required specialized training. Despite being hired in 2021 and starting the CDC's Nursing Home Infection Preventionist Training Course in 2022, she had completed only 5 of the required 23 modules.
The missing training modules covered critical areas including advanced surveillance techniques, outbreak investigation, antimicrobial stewardship, and environmental infection control. This training gap likely contributed to the systemic program failures documented throughout the inspection.
Staff interviews revealed widespread confusion about EBP requirements. One certified nursing assistant believed she "usually only wore gloves" for EBP residents and had stopped wearing gowns because she was told they were "no longer required because the wounds were covered." This misunderstanding of infection control principles demonstrates inadequate staff education about how pathogens can spread through contact with contaminated clothing.
Additional Issues Identified
Beyond the major infection control violations, inspectors documented the facility's failure to make personal protective equipment readily available in areas where EBP residents received care. The facility stored gowns in residents' room closets rather than at entry points where staff could easily access them before providing care, creating barriers to compliance with protective protocols.
The inspection also revealed gaps between the facility's written policies and actual practices, with staff operating under informal guidelines that contradicted established medical standards for infection prevention and antibiotic stewardship.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Strand-kjorsvig Community Rest Home from 2025-05-08 including all violations, facility responses, and corrective action plans.
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