Federal inspectors documented widespread infection control violations at Centerville Care and Rehab Center, including failures to follow enhanced barrier precautions for three residents with catheters and wounds, creating potential risks for cross-contamination and healthcare-associated infections.
CENTERVILLE, SD - A May 2025 federal inspection at Centerville Care and Rehab Center revealed systemic failures in infection prevention and control practices that put residents at risk for healthcare-associated infections. Inspectors documented violations ranging from improper use of protective equipment during wound and catheter care to inadequate cleaning of shared equipment and food service areas.
Enhanced Barrier Precautions Not Followed
The most concerning findings involved three residents who required enhanced barrier precautions during care but did not receive them. Enhanced barrier precautions require staff to wear gowns and gloves during any contact care for residents with certain conditions, including indwelling catheters and wounds.
Resident 1, who had a suprapubic catheter and wounds to his tailbone and buttock, reported that staff wore gloves but no gowns when emptying his catheter or performing wound care. Inspectors found no personal protective equipment available in his room and no signage indicating the need for enhanced precautions.
Similarly, Resident 5, who had both a suprapubic catheter and colostomy, stated that staff "sometimes" wore gowns during catheter emptying and personal care, but not consistently. While his bathroom had a sign indicating enhanced barrier precautions were required, staff did not follow the protocol reliably.
Resident 25, who had an indwelling catheter following foreskin surgery, also received inconsistent protection. Staff used gloves during catheter care but not gowns, and his room had no signage about the precaution requirements.
Enhanced barrier precautions represent a critical defense against the spread of multidrug-resistant organisms in healthcare settings. Catheters create direct pathways for bacteria to enter the body, and wounds provide vulnerable sites for infection. When staff fail to use proper barriers, they can transfer organisms between residents or introduce new pathogens during care procedures.
A nursing assistant confirmed she provided care for Residents 5 and 25 and knew the correct process for using protective equipment, but admitted she "did not always use PPE when emptying or providing cares."
The MDS Coordinator, who served as the facility's infection preventionist, acknowledged that enhanced barrier precautions should have been included in care plans for residents with wound care and catheter care needs. She stated she thought staff would know to use the precautions based on meetings and annual training, without ensuring documentation or consistent implementation.
Shared Equipment Not Properly Sanitized
Inspectors observed multiple instances where staff failed to clean shared resident equipment between uses, creating opportunities for cross-contamination.
On May 20, a nursing assistant returned a mechanical lift from a resident's room without cleaning it. When questioned, she explained that staff were "supposed to clean the shared equipment, such as lifts, between each resident use, but that only occurred when the equipment was visibly dirty or they had time to clean it."
The day before, inspectors observed a stand-aid being moved from one resident's room to another without any cleaning. The sanitizing wipes available at the nurses' station require surfaces to remain visibly wet for two minutes to effectively kill microorganisms, but staff were not following this protocol.
Mechanical lifts and stand-aids contact residents' bodies and clothing during transfers. When these devices move between rooms without proper disinfection, they can carry skin flora, respiratory droplets, and environmental contaminants from one resident to another. This creates particular risks for residents with compromised immune systems or open wounds.
The MDS Coordinator confirmed that staff received training on cleaning lift equipment between each resident use during orientation and annually, indicating a gap between policy and practice.
Hand Hygiene Lapses During Meal Service and Care
Proper hand hygiene represents one of the most fundamental infection control measures, yet inspectors documented multiple failures.
During a meal service on May 18, a nursing assistant seated between two residents who needed full feeding assistance got up from the table and used her hands and arms to help another staff member lift a resident in their wheelchair. She then returned to the table and continued assisting the two residents with eating without washing or sanitizing her hands.
When interviewed later, the nursing assistant confirmed "she should have had hand sanitizer at the table and used it between assisting the residents."
Hand hygiene between resident contacts prevents the transmission of pathogens that cause respiratory infections, gastrointestinal illnesses, and skin infections. During meal service, this becomes especially critical as staff may transfer organisms directly into residents' mouths through feeding utensils.
A dietary aide responsible for delivering fresh water mugs demonstrated similar lapses. Inspectors observed her taking clean mugs into resident rooms and returning with dirty mugs without performing hand hygiene between handling clean and dirty items or between entering different rooms. She stated she was unaware that handwashing was required between these tasks.
The dietary manager, who had recently completed ServSafe training, acknowledged "the current water mug pass process was not sanitary." She revealed she had not made any changes to the process since starting in September 2024 and did not provide regular training for dietary staff beyond working with new employees for a few days.
Whirlpool Tub Cleaning Procedures Inconsistent
Two nursing assistants who served as bath aides described completely different cleaning processes for the whirlpool tub and chair, neither of which followed the facility's written policy.
One assistant reported spraying the tub and chair with Clorox disinfecting spray between baths, rinsing, and drying with a towel. She only performed the full disinfection process with the facility's designated sanitizing chemical at the end of the day after all baths were completed.
The second assistant described using the Clorox spray to clean the tub and chair, scrubbing with a towel, letting it sit briefly, then spraying off with water. She stated she preferred the bleach product and did not use the facility's designated sanitizing disinfectant. Both assistants learned their techniques from other nursing assistants rather than formal training.
The facility's written policy specifies a detailed procedure that includes filling the tub with the shower chair inside, adding premixed disinfectant, running the whirlpool jets, thoroughly spraying and scrubbing all surfaces, and allowing the disinfectant to remain visibly wet for 10 minutes before rinsing. This process should occur after each resident use.
Whirlpool tubs present unique infection control challenges because the jet system can harbor bacteria in areas difficult to reach with surface cleaning alone. Running disinfectant through the jets ensures the entire system receives treatment. The 10-minute wet contact time allows the chemical to effectively kill pathogens including bacteria, viruses, and fungi that may be present.
Inspectors also noted that the paint on the chair legs was completely chipped away at each end, exposing rusted metal that could not be properly cleaned or disinfected.
Kitchen Sanitation Deficiencies
The kitchen inspection revealed multiple areas with inadequate cleaning that could compromise food safety.
Inspectors documented dust on top of the plate storage cabinet where plate covers were stored, food debris and stains on dish storage shelves, and food debris and stains on the beverage serving cart that held prepared residents' beverages. The kitchen floor under the stove and storage racks was soiled with food debris and dirt.
Drawers containing clean utensils had food stains and food debris in them. Cabinet and drawer handles showed accumulated food debris, and the refrigerator door was soiled.
A cook acknowledged "placing clean utensils in a dirty drawer would not be sanitary" and agreed there was no scheduled kitchen cleaning task for the inside of drawers and cabinets.
The dietary manager stated all kitchen staff were responsible for cleaning if they noticed something unclean, but she agreed the observed conditions indicated cleaning tasks were not being completed as required.
Food debris in storage areas attracts pests and provides nutrients for bacterial growth. When clean dishes and utensils are placed in contaminated storage areas, they can pick up organisms that then transfer directly to residents' food during meal service.
Infection Preventionist Lacked Required Certification
The facility's designated infection preventionist, who also served as MDS Coordinator, had not completed the required certification despite being in the role since 2019.
She explained she had completed all training modules required to take the certification test but had not taken the actual exam. She told inspectors she had expressed to the previous administrator that she felt she had too many work responsibilities and was unable to complete the test.
The Director of Nursing believed the MDS Coordinator had exceeded the time requirement to take the certification test and would need to repeat the entire training course. The emergency permit holder administrator, hired in January 2025, acknowledged responsibility for ensuring the training requirement was met.
Federal regulations require facilities to designate a qualified infection preventionist with specialized training to oversee the infection prevention and control program. This training provides essential knowledge about surveillance, outbreak investigation, antibiotic stewardship, and implementation of evidence-based practices.
Staffing Data Reporting Failures
Beyond infection control, inspectors identified failures in the facility's Payroll Based Journal reporting to the Centers for Medicare & Medicaid Services. The facility could not document 24-hour licensed nursing coverage for 22 days in May 2024 and 21 days in June 2024.
The Director of Nursing, who was responsible for covering shifts to ensure continuous licensed nursing coverage, was a salaried employee who did not keep records of hours worked and was not required to use the time clock. This made the staffing data unverifiable.
Accurate staffing information allows regulators and the public to assess whether facilities maintain adequate nursing coverage to meet residents' care needs. The inability to verify coverage raises questions about whether residents consistently had access to licensed nursing care.
The emergency permit holder administrator stated she was hired in January 2025, after the previous administrator who left at the end of December 2024 had failed to submit Payroll Based Journal data or submitted it incorrectly.
Regulatory Context
The inspection identified violations of federal participation requirements for skilled nursing facilities. The facility must submit a plan of correction detailing how it will address each deficiency and prevent recurrence.
Infection prevention and control represents a fundamental responsibility for nursing homes, where residents often have multiple chronic conditions, weakened immune systems, and frequent exposure to antibiotics that increase infection risks. The Centers for Disease Control and Prevention estimates that healthcare-associated infections affect approximately one in ten nursing home residents at any given time.
The deficiencies documented at Centerville Care and Rehab Center illustrate how breakdowns in basic infection control practices can occur across multiple areas simultaneously, from direct resident care to environmental cleaning to administrative oversight.
Residents and families seeking information about the facility's correction plan should contact Centerville Care and Rehab Center directly or the South Dakota Department of Health.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Centerville Care and Rehab Center Inc from 2025-05-21 including all violations, facility responses, and corrective action plans.
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