The violation occurred during care for a 72-year-old woman with multiple health conditions including congestive heart failure, diabetes, and morbid obesity. The resident required substantial assistance with personal hygiene and was occasionally incontinent of urine and always incontinent of bowel.
Federal inspectors observed the improper care on August 26 at 11:10 a.m. Certified Nurse's Aide #111 brought soapy and wet washcloths and a towel into the room, laying them on the bed. The aide washed the resident's buttocks and anal area, then took the washcloths to the sink to rinse them.
After removing her gloves and washing her hands, the aide applied new gloves and used the same washcloths to clean under the right side of the resident's abdomen. She repeated this process, rinsing the washcloths at the sink, washing her hands, and applying new gloves before using the same cloths to wash the resident's vaginal area.
The aide continued the pattern, using the rinsed washcloths to clean the left side of the resident's abdomen before finishing the care.
When interviewed 18 minutes later, the aide acknowledged she had not followed proper infection control procedures during the incontinence care.
The facility's own policy, revised in October 2010, explicitly prohibits this practice. The perineal care procedure states that staff should "not use the same cloth or water to clean the urethra or labia" and requires washing "from inside outward" using "downward strokes."
The policy requires specific sequencing for female residents: wash the perineal area from front to back, separate the labia and wash downward, continue washing the perineum moving from inside outward including the thighs, then have the resident turn to wash the rectal area from "the base of the labia towards and extending over the buttock."
This systematic approach prevents bacteria from the anal area from contaminating the urethral opening, which can lead to urinary tract infections. The resident in this case had been admitted in July 2023 and required dependent care for toileting, bathing, and dressing.
Despite having intact cognition and only needing setup assistance with eating, the resident's multiple medical conditions and incontinence made proper hygiene care critical to preventing infections.
The inspection was conducted in response to a complaint filed under number 2600023. Federal inspectors reviewed six residents' records as part of their investigation into urinary tract infections at the 72-bed facility.
New Dawn Rehabilitation and Healthcare Center is disputing the citation. The facility has not provided details about what specific aspects of the finding it contests.
The violation represents a failure in the facility's infection prevention and control program, which federal regulations require all nursing homes to maintain and implement. While inspectors classified the harm level as minimal, improper infection control during intimate care can lead to serious urinary tract infections, particularly in elderly residents with compromised immune systems.
The resident affected by the improper care also had erythema intertrigo, a skin condition that develops in skin folds and can worsen with poor hygiene practices. Her medical conditions, including diabetes and morbid obesity, put her at higher risk for infections when proper protocols are not followed.
Federal inspectors noted that the aide's practice of rinsing washcloths between body areas and changing gloves showed some awareness of infection control principles, but the fundamental error of using the same cloths on multiple areas violated basic hygiene standards that have been established medical practice for decades.
The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs. The findings will be publicly disclosed 14 days after the facility receives the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Dawn Rehabilitation and Healthcare Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
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