The violation occurred during federal inspectors' visit on August 26, when they followed CNA E into the room of a resident with a suprapubic catheter who was on enhanced barrier precautions due to a history of extended-spectrum beta-lactamase infection in the urine.
The inspector watched CNA E don personal protective equipment before entering the room at 3:15 PM. The aide pushed the resident into a shared bathroom, helped them pivot to the toilet, and pulled down their pants before opening the catheter and emptying urine into a graduate container.
What happened next violated the facility's own infection control protocols.
CNA E threw the resident's used brief onto the bathroom floor instead of in the garbage. After emptying the catheter and placing the graduate container on the floor, the aide used the same contaminated gloves to clean the resident's bottom and pull their pants back up.
The contamination spread beyond the bathroom. CNA E opened the bathroom door with the same gloves, walked the resident to their wheelchair, and touched the wheelchair with contaminated hands. The aide then wheeled the resident to bed and helped them lie down, all while wearing the same gloves that had handled catheter drainage.
The aide removed the resident's shoes with contaminated gloves, rearranged the bedside table that held a lunch tray, and placed the call light within the resident's reach. Only after completing all these tasks did CNA E walk to the door, remove the protective equipment, and wash their hands.
When interviewed ten minutes later, CNA E acknowledged the error. The aide told the inspector they "should have changed gloves right after emptying graduate with urine before touching other surfaces and CNA E did not."
The facility's own policy, revised in January 2025, specifically addresses enhanced barrier precautions for high-contact resident care activities. These include changing linens, changing briefs or assisting with toileting, and device care involving urinary catheters.
Director of Nursing B confirmed the violation when interviewed the following morning. The DON told inspectors the expectation is that personal protective equipment should be donned upon entering enhanced barrier precaution rooms and "frequent glove changes are to be performed."
After hearing about the inspector's observation, the director of nursing stated that "CNA E should have discarded contaminated gloves after emptying R4's urine in graduate, sanitized, and then reapplied new gloves."
The resident affected by the improper infection control practices has a suprapubic catheter, a surgically placed tube that drains urine directly from the bladder through the abdomen. These devices require careful handling to prevent introducing bacteria that could cause serious urinary tract infections.
Extended-spectrum beta-lactamase bacteria, the reason this resident was on enhanced barrier precautions, produce enzymes that make them resistant to many common antibiotics. When these organisms spread between residents or contaminate surfaces, they can cause difficult-to-treat infections.
The shared bathroom where the violation occurred serves both this resident and their neighbor, creating additional opportunities for cross-contamination when proper protocols aren't followed.
Federal inspectors cited the facility for failing to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The violation was classified as causing minimal harm or potential for actual harm.
The inspection found that one out of three residents reviewed was affected by the facility's failure to properly implement infection control procedures. The resident with the catheter continues to live at Dove Healthcare-Superior, where staff are expected to follow enhanced barrier precautions during every interaction to prevent the spread of antibiotic-resistant bacteria.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dove Healthcare - Superior from 2025-08-27 including all violations, facility responses, and corrective action plans.