Highland Square Nursing: Infection Control Failures - OH
The August 19 incident at Highland Square Nursing and Rehabilitation involved a resident requiring enhanced barrier precautions due to a feeding tube inserted directly into his stomach. Federal inspectors observed the certified nursing assistant violating multiple infection control protocols during routine incontinence care.
The resident, admitted in March with left-side paralysis and cognitive deficits, depends entirely on staff for personal care. He requires constant assistance due to complete bowel and bladder incontinence.
His physician ordered enhanced barrier precautions on March 25 specifically because of his gastrostomy tube, which provides nutrition directly to his stomach. The facility's care plan mandated that staff wear both gloves and gowns during all personal care to prevent dangerous infections.
But CNA #388 put on gloves only. No gown.
After removing the resident's soiled brief containing fecal matter and contaminated bed linens, the nursing assistant placed the waste materials directly on the floor next to the resident's bed. The assistant then cleaned feces from the resident's groin and buttocks area.
Without removing the contaminated gloves or washing hands, CNA #388 immediately handled clean bed linens. The assistant also touched the resident's over-bed table and bed control buttons with the same gloves that had just removed fecal matter.
When questioned by inspectors, CNA #388 acknowledged knowing the resident required enhanced barrier precautions. The assistant admitted to skipping the required gown and confirmed placing contaminated items on the floor.
The nursing assistant also verified touching clean surfaces without first removing soiled gloves or performing hand hygiene.
Highland Square's own enhanced barrier precaution policy, dating to 2014, explicitly requires gowns and gloves during high-contact activities including changing briefs and linens. The policy states these precautions minimize spread of multidrug-resistant organisms, particularly for residents with medical devices like feeding tubes.
The facility's separate perineal care policy instructs staff to remove gloves and wash hands after cleaning the rectal area and before repositioning bed linens. However, this policy provides no guidance for handling soiled linens and briefs once removed from residents.
Enhanced barrier precautions exist because residents with indwelling medical devices face elevated infection risks. Gastrostomy tubes create direct pathways into the digestive system, making contamination potentially life-threatening.
The resident affected by these violations already faces significant health challenges. His medical record shows left-side hemiplegia has left him unable to move his left arm and leg. Cognitive communication deficits compound his vulnerability.
Atrial fibrillation and hypertension further complicate his condition. At 64 residents, Highland Square serves a population where infection control failures can rapidly escalate into serious medical emergencies.
Federal inspectors discovered this violation during a complaint investigation, suggesting other unreported incidents may have occurred. The facility's infection control program failed at multiple levels during this single observation.
Staff training clearly did not prevent the violations. CNA #388 knew the enhanced precaution requirements but chose not to follow them. The nursing assistant understood proper glove removal and hand hygiene protocols but ignored them.
Placing contaminated materials on the floor created additional infection risks beyond the immediate resident care. Fecal matter on flooring can spread pathogens throughout the facility, affecting other vulnerable residents.
The resident requiring these precautions remains dependent on the same staff who violated his safety protocols. His complete reliance on others for basic hygiene makes him unable to protect himself from such contamination.
Highland Square's policies acknowledge the infection risks but failed to ensure compliance during actual care delivery. The gap between written procedures and observed practice represents a fundamental breakdown in resident protection.
This resident's feeding tube will likely remain in place indefinitely, requiring continued enhanced precautions. Each future care interaction carries similar contamination risks if staff continue ignoring established protocols.
The contaminated gloves that touched clean linens and bed controls created lasting infection hazards in the resident's immediate environment. Every surface the nursing assistant contacted became a potential source of dangerous bacteria.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Square Nursing and Rehabilitation from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
HIGHLAND SQUARE NURSING AND REHABILITATION in AKRON, OH was cited for violations during a health inspection on August 20, 2025.
Federal inspectors observed the certified nursing assistant violating multiple infection control protocols during routine incontinence care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.