Fir Lane Care: Infection Control Violations - WA
The nurse, identified as Staff C, entered and exited resident rooms repeatedly on August 20 without performing hand hygiene, despite facility policy requiring hand washing before and after patient contact. She handled medication carts, computer equipment, and personal items like keys and pens between patient encounters.
Inspectors documented the violations during a complaint investigation at Fir Lane Care, finding that two of three nurses observed failed to follow basic infection control protocols during medication administration.
A family member who visits daily had complained about the practice weeks earlier. The relative told inspectors on August 14 that nurses routinely entered their family member's room to give medications without washing hands "coming and/or going." The family member specifically noted that nurses administered eye drops without gloves and failed to wash hands afterward.
During the inspection, Staff C's violations were extensive and systematic. After taking one resident's blood pressure and temperature, she left the room without hand hygiene, used her pen to document on paper, then performed hand hygiene before retrieving keys from her pocket. She opened the medication cart, removed medications, used a computer mouse, and entered the resident's room again without washing her hands.
Inside the room, Staff C administered medications, collected the resident's used drinking cup and paper pill container, then exited without hand hygiene to document on the computer.
The pattern repeated with the next resident. Staff C entered without hand washing, placed her hands around the resident's head to speak into their ear, held their arm to attach a blood pressure cuff, and took vital signs. After exiting to document and gather medications, she returned without hand hygiene to adjust the resident's linens, move pillows, and reposition their bedside table.
Staff C then put on gloves to administer eye drops but removed them and immediately applied a medication patch to the resident's back without washing her hands. She left the room without hand hygiene, retrieved keys from her pocket, opened the medication cart, and returned the keys to her pocket.
A licensed practical nurse designated as Staff D also violated protocols while caring for a resident under enhanced barrier precautions. These special infection control measures require strict hand hygiene to prevent disease transmission.
Staff D properly performed hand hygiene and wore protective gown and gloves when entering the resident's room on August 20. The nurse prepared to administer intravenous medication, using a syringe to flush the resident's IV access site. When the IV solution wouldn't mix properly, Staff D removed the protective gown and gloves but failed to wash hands before leaving the room.
The nurse then handled keys, opened the medication cart, assessed its contents, and walked down the hallway without performing required hand hygiene.
The facility's own policy, though undated, clearly specified when hand hygiene was required: immediately before touching a patient, after touching a resident, after touching the resident's environment, and immediately after glove removal.
Staff B, the Director of Nursing, confirmed these expectations during an interview on August 21. She told inspectors that staff were expected to perform hand hygiene when entering and exiting resident rooms, after removing gloves, and before and after touching residents or their environment.
The violations occurred despite widespread medical consensus that hand hygiene represents the single most effective method for preventing healthcare-associated infections. Nursing home residents face particular vulnerability due to compromised immune systems, chronic conditions, and close living quarters that facilitate disease transmission.
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs specifically to protect residents from these risks. The repeated failures at Fir Lane Care demonstrated a breakdown in basic safety protocols during one of the most routine yet critical aspects of resident care.
Inspectors classified the violations as causing minimal harm or potential for actual harm, but noted they placed residents at risk for infection spread and diminished quality of life.
The family member's daily observations suggest the hand hygiene failures weren't isolated incidents but represented ongoing practice patterns that potentially exposed multiple residents to preventable infections during routine medication administration.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fir Lane Care from 2025-08-21 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 20, 2026 · Our methodology
FIR LANE CARE in SHELTON, WA was cited for violations during a health inspection on August 21, 2025.
She handled medication carts, computer equipment, and personal items like keys and pens between patient encounters.
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.