St Edna Subacute Cited for Multiple Infection Control Violations in Federal Inspection
SANTA ANA, CA - Federal health inspectors documented widespread infection control failures at St Edna Subacute and Rehabilitation Center during a May 2025 survey, citing the facility for practices that placed residents at risk for transmission of communicable diseases and infections.
The 555093-licensed facility at 1929 N. Fairview Street received citations after surveyors observed staff failing to follow proper isolation protocols, contaminated medical equipment, and multiple hand hygiene violations during medication administration and resident care.
Contaminated Medical Equipment Discovered
Inspectors found visible contamination on critical medical equipment used for multiple residents. During an examination of Medication Cart 2 on May 8, 2025, surveyors observed red-brown smudges on the back side of a glucometer, a device used to test blood glucose levels in residents with diabetes.
When questioned about the substance, the facility's Unit Manager stated she did not know what the smudges were. Blood glucose monitoring requires piercing the skin to obtain a blood sample, making any contamination on the device a potential vector for bloodborne pathogen transmission between residents.
The presence of unidentified biological material on shared medical equipment violates basic infection control principles. Glucometers should be cleaned and disinfected after each use according to manufacturer instructions and facility protocols. Any visible contamination indicates a breakdown in cleaning procedures that could expose multiple residents to infectious agents.
Isolation Protocol Failures Documented
Inspectors documented a serious breach in contact enteric precautions for a resident with Clostridium difficile infection, a highly contagious bacteria that causes severe diarrhea and colitis. Resident 131 had physician orders for contact enteric precautions beginning April 23, 2025, which required hand washing with soap and water upon leaving the room.
During an optometry visit on May 7, 2025, the optometrist was incorrectly informed by facility staff that the resident had isolation precautions for a urinary tract infection rather than C. diff. The optometrist wore appropriate personal protective equipment but used alcohol-based hand sanitizer when leaving the room instead of washing with soap and water.
This distinction matters because C. diff produces spores that resist alcohol-based sanitizers. Only soap and water physically removes the spores from hands. The optometrist then entered another resident's room wearing a new gown and gloves but potentially carrying C. diff spores on their hands, creating a direct pathway for transmission.
The optometrist's assistant confirmed they were also told the isolation was for a urinary tract infection. This communication failure meant external healthcare providers could not follow appropriate precautions, potentially spreading the infection to other residents.
Enhanced Barrier Precautions Not Followed
In another isolation protocol failure, a certified nursing assistant was observed providing high-contact care to Resident 38 without wearing the required gown. The resident had physician orders for enhanced barrier precautions beginning April 1, 2025, for a diabetic wound on the left big toe.
Enhanced barrier precautions are designed to prevent transmission of multidrug-resistant organisms through targeted use of gowns and gloves during activities involving substantial physical contact. The facility's policy specified that staff must wear gowns and gloves for dressing, bathing, transferring, changing linens, providing hygiene, and wound care.
On May 7, 2025, inspectors observed the CNA turning Resident 38 on his side to reposition sheets and dressing him in a new gown. The CNA wore gloves but no protective gown during this high-contact care. Two bags containing soiled linen were on the floor next to the bed.
When interviewed, the CNA acknowledged understanding the enhanced barrier precaution requirements and confirmed Resident 38 required these precautions due to his heel wound. The CNA verified she should have worn a gown but did not.
Multidrug-resistant organisms can colonize wounds and spread through direct contact with skin, clothing, or contaminated surfaces. Failing to wear appropriate barriers during extensive physical contact creates opportunities for these dangerous bacteria to transfer to the caregiver's clothing and subsequently to other residents.
Widespread Hand Hygiene Violations
Inspectors observed multiple instances of improper hand hygiene during medication administration, one of the most critical times for preventing cross-contamination between residents.
During a morning medication pass on May 7, 2025, LVN 6 was observed checking blood sugar and administering medications to Resident 102 through a feeding tube. The nurse performed numerous tasks without appropriate hand hygiene between contacts with contaminated and clean items.
The LVN disinfected blood pressure equipment while wearing gloves, then removed the gloves without washing hands before unlocking the medication cart and gathering supplies. She entered the resident's room without hand hygiene, adjusted the resident's oxygen tubing, then used the same gloves to perform a finger stick for blood sugar testing.
After obtaining the blood sample and removing gloves, the nurse left the room without washing hands, re-entered to pick up a remote control from the floor and place it on the bed, then left again without hand hygiene. This pattern continued through multiple entries and exits, with the nurse touching clean medical supplies, the resident, environmental surfaces, and medical equipment without hand hygiene between contacts.
Hand hygiene represents the single most effective method for preventing healthcare-associated infections. Each failure to wash hands or use sanitizer between tasks creates an opportunity to transfer microorganisms from contaminated surfaces to clean supplies, from one body site to another on the same resident, or from one resident to another.
Eye Medication Contamination
During medication administration to Resident 40, inspectors observed the tip of an artificial tears dropper touch the resident's eyelashes. This contact contaminated the dropper, making the entire bottle unsafe for future use.
Ophthalmic medications require strict aseptic technique because the eye has limited natural defenses against infection. Once a dropper tip contacts the eye, eyelashes, or any other surface, bacteria can contaminate the tip and subsequently grow in the solution bottle, particularly if the medication does not contain preservatives.
Using a contaminated eye medication bottle could introduce bacteria directly onto the corneal surface, potentially causing serious eye infections. The nurse acknowledged during follow-up interview that the dropper becomes unsafe if it touches any surface, but stated she did not see the contact occur.
Additional Infection Control Lapses
Inspectors documented several other infection control violations:
Personal items in treatment supplies: A nurse's personal cell phone was stored in the top drawer of the treatment cart alongside sterile wound care supplies. Personal electronics harbor significant bacterial contamination and should never be stored with medical supplies.
Contaminated surface contact: A janitor placed his face shield on an upside-down dirty linen cart lid after working in the contaminated laundry area, then later picked it up and placed it on a hook. This transferred contamination from the dirty linen area to the protective equipment.
Improper linen transport: A laundry assistant transported clean resident clothing in an uncovered cart through facility hallways. The clean clothes were observed touching hallway handrails, exposing them to environmental contamination before being delivered to residents.
Monitoring and Surveillance Failures
Beyond direct care violations, inspectors found the facility failed to implement required infection monitoring programs. The Infection Preventionist did not review any of the 25 antibiotic orders placed in April 2025 to determine if suspected infections met clinical criteria.
When the IP reviewed one resident's record during the survey, she confirmed the resident did not meet criteria for infection but had received a full seven-day course of antibiotics. The IP acknowledged other residents may have received inappropriate antibiotics because no April reviews were conducted.
The facility's Legionella Water Management Program specified quarterly testing, but records showed testing occurred only annually in February 2024 and March 2025. Legionella bacteria can grow in water systems and cause serious pneumonia, particularly in elderly populations. Regular testing helps identify problems before residents become ill.
Regulatory Context and Facility Response
St Edna Subacute and Rehabilitation Center received these citations under federal tag F880 (Infection Prevention and Control Program) and F881 (Antibiotic Stewardship Program) during the May 13, 2025 survey. The deficiencies were classified as causing minimal harm or potential for actual harm, affecting some residents.
The Administrator and Director of Nursing were informed of the findings and acknowledged the violations. The facility is required to submit a plan of correction detailing how it will address each deficiency and prevent recurrence.
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs designed to provide a safe, sanitary environment. These programs must include surveillance systems to identify infections, protocols to prevent transmission, and staff education on proper techniques.
For complete details of the inspection findings and the facility's plan of correction, the full survey report is available through the Centers for Medicare & Medicaid Services Nursing Home Compare website.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Edna Subacute and Rehabilitation Center from 2025-05-13 including all violations, facility responses, and corrective action plans.
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