COLVILLE, WA - A nursing home inspection revealed significant infection control failures during a Norovirus outbreak that affected 27 of 61 residents and 33 of 86 staff members at Prestige Care & Rehabilitation - Pinewood Terrace, with violations documented across all three nursing units during the May 2025 survey.
Outbreak Response and Reporting Failures
The outbreak began on May 2, 2025, when the first resident developed gastrointestinal symptoms. Despite laboratory confirmation of Norovirus four days later on May 6, the facility failed to promptly notify the appropriate authorities. The infection preventionist contacted the Washington State Department of Health on May 12, 2025—ten days after identifying the first case—rather than reporting immediately to both state survey agencies and local health departments as required.
When interviewed, the local county health department's Community Health Specialist confirmed they had not been notified of the laboratory-confirmed outbreak and stated that outbreak reporting was required. The specialist indicated their department routinely assists facilities during outbreaks by providing guidance on isolation protocols and staff exclusion policies, following Centers for Disease Control and Prevention guidelines that recommend staff remain off work for 48 hours after symptoms resolve.
The facility's infection preventionist initially stated they had called the local health department three times and was told Norovirus was not reportable, though county officials contradicted this claim. This communication breakdown delayed implementation of comprehensive outbreak control measures and external oversight during a critical period when the virus spread rapidly through the facility.
Inconsistent Isolation Precautions and Signage Confusion
Throughout the survey period, inspectors documented widespread confusion and inconsistency in implementing contact precautions. The facility used non-standardized signage that created uncertainty among staff about when and what type of personal protective equipment to wear. Multiple residents who required contact precautions either had no signage posted or had conflicting signs that staff members couldn't interpret correctly.
On May 12, a nursing assistant was observed entering a resident's room that had a red stop sign and yellow PPE bag at the door, wearing only disposable gloves—no gown, mask, or eye protection. The signage failed to specify what type of isolation was in place, instructing only that staff "ask the nurse before entering."
Another resident's room displayed signage for both Enhanced Barrier Precautions and Contact Precautions simultaneously, causing a licensed practical nurse to incorrectly tell surveyors that contact precautions were only needed during wound care, not for routine care activities. This resident had an intravenous line in place for antibiotic administration, which should have triggered enhanced precautions for all high-contact care activities.
Most concerning was the situation with Resident 58, whose door displayed "Special Droplet/Contact Precaution" signage requiring N95 respirators, eye protection, gloves, and gowns. Multiple staff members were observed entering this room over several days without donning any protective equipment. When questioned, one nursing assistant acknowledged they should have worn PPE as instructed but hadn't, while another staff member incorrectly stated PPE was only required when providing direct care, not when delivering meal trays.
Medical Significance of Norovirus Transmission
Norovirus is highly contagious and spreads through multiple routes: direct contact with infected individuals, touching contaminated surfaces, and consuming contaminated food or water. The virus can survive on surfaces for days and is resistant to many common disinfectants. In healthcare settings, particularly nursing homes where residents have compromised immune systems and underlying health conditions, Norovirus poses serious health risks.
The primary danger is severe dehydration resulting from persistent vomiting and diarrhea. Older adults are especially vulnerable because they have reduced physiological reserves and may not recognize thirst cues or be able to communicate their needs effectively. Dehydration can rapidly progress to electrolyte imbalances affecting heart rhythm, blood pressure regulation, and kidney function.
One resident documented in the inspection report experienced critically low blood pressures—88/60 on three consecutive days and 92/60 on a fourth day—during their illness period. Normal blood pressure averages 120/80, making readings in the 80s dangerously low and indicative of significant fluid loss. Despite these concerning vital signs, there was no documentation that the healthcare provider had been notified or that interventions were implemented to address potential dehydration.
The facility's nurse practitioner, when reviewing the case, stated they would have expected notification of such low blood pressures and that any resident with gastrointestinal illness combined with blood pressure readings of 88/60 would require provider notification due to dehydration concerns. This gap in communication represented a critical failure in the clinical response to outbreak-related complications.
Staff Exclusion Policy Violations
Perhaps the most alarming finding involved staff members working while actively symptomatic with Norovirus. CDC guidelines clearly recommend that ill healthcare workers be excluded from work for a minimum of 48 hours after symptoms resolve to prevent transmission to vulnerable residents. The facility instructed staff they could return to work after being symptom-free for only 24 hours—half the recommended duration.
Documentation revealed that 14 staff members became ill on May 4, 2025, with additional cases continuing through May 9. The infection preventionist acknowledged they stopped tracking ill employees after reaching approximately 25 cases because staff illnesses were no longer being reported to them, suggesting the actual number may have been higher than the 33 documented cases.
Most egregiously, an agency nurse reported being instructed to work on May 15, 2025, despite having a documented fever of 101.3 degrees Fahrenheit. Text message records showed the nurse communicated their fever to the facility, yet was still expected to report for duty. The nurse took acetaminophen to reduce the fever, worked a double shift that evening, continued working the following day while still symptomatic, and ultimately required hospital evaluation where they were diagnosed with gastroenteritis.
Requiring symptomatic staff to work during an active Norovirus outbreak represents a fundamental violation of infection control principles. Ill healthcare workers can shed virus particles and contaminate surfaces, equipment, and residents through direct contact, perpetuating outbreak transmission and potentially introducing the infection to previously unaffected nursing units.
Enhanced Barrier Precautions Implementation Gaps
Beyond outbreak-specific contact precautions, the facility failed to implement Enhanced Barrier Precautions for residents with indwelling medical devices. These precautions require staff to wear gowns and gloves during high-contact care activities—such as bathing, dressing, transferring, and toileting—for residents with feeding tubes, urinary catheters, intravenous lines, dialysis ports, or wounds.
Multiple residents with such devices had no signage indicating EBP requirements and no PPE carts positioned at room entrances. One resident had a urinary catheter awaiting removal, another had a dialysis port with visible dressing on their chest, and a third was receiving tube feeding formula through an abdominal tube with feeding equipment visible in the room. None of these rooms had appropriate precaution signage or readily available PPE supplies.
The facility's policy stated EBP should be maintained for the resident's entire length of stay unless devices were removed or wounds healed. However, staff demonstrated inconsistent understanding of when EBP applied versus standard contact precautions. The infection preventionist acknowledged they hadn't completed routine rounds to verify appropriate signage was posted, representing a breakdown in systematic monitoring.
Additional Issues Identified
The inspection revealed several secondary concerns related to the infection prevention program. The facility's infection prevention policies had not been reviewed on the required annual schedule. While the transmission-based precautions policy was current with an April 2024 revision date, other policies were significantly outdated: the surveillance policy was last revised in September 2020, antibiotic stewardship in October 2022, and the influenza program in August 2023. One policy for employee influenza immunizations had an implausible release date of October 2027.
When questioned about policy review responsibilities, the infection preventionist was uncertain who conducted annual reviews and assumed the corporate office handled this function. This uncertainty indicated lack of clarity about accountability for maintaining current, evidence-based infection prevention practices.
Staff education and competency verification also appeared inconsistent. Multiple direct care staff demonstrated through their actions that they either didn't understand isolation precautions or chose not to follow them. When the regional director reviewed the findings, they acknowledged that non-standardized precaution signage contributed to staff confusion and that if staff had to search for PPE supplies rather than finding them readily available, compliance rates would decline.
The outbreak ultimately affected all three nursing units in the facility. While no residents required hospitalization specifically for Norovirus complications, several residents experienced symptoms lasting multiple days. Two residents developed new onset illness during the survey period—five and twelve days after the facility had declared the outbreak resolved—suggesting ongoing transmission that the facility had not detected or adequately controlled.
Facility representatives acknowledged during exit interviews that breaches in infection control practices contributed to Norovirus transmission and committed to implementing corrective measures including standardized signage, staff re-education on precaution protocols, improved communication systems for reporting resident illness, and adherence to evidence-based guidelines for staff exclusion during outbreaks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prestige Care & Rehabilitation - Pinewood Terrace from 2025-05-23 including all violations, facility responses, and corrective action plans.
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