The nurse, identified in inspection records as LPN #460, was hired on February 5 and had no TB skin test results in her personnel file when state inspectors arrived in September. Human Resource Director #410 confirmed during a September 9 interview that the file contained no tuberculosis screening documentation.
Two other employees received partial testing that violated the facility's own screening requirements. Housekeeper #400, hired in September 2024, completed only the first step of a mandatory two-step tuberculin skin test. The form documenting her screening showed the second test was due within one to three weeks of the first, but that section remained blank nearly a year later.
Certified Nursing Assistant #450 faced identical problems. Hired on June 25, she received the first tuberculin skin test on her start date, with negative results recorded two days later. But like the housekeeper, she never received the required second test.
The facility's tuberculosis risk assessment mandated baseline skin testing with a two-step process for all healthcare workers. The policy, revised in August 2019, required employees to be screened for both latent tuberculosis infection and active TB disease before beginning work.
Human Resource Director #410 acknowledged during her interview that both the housekeeper and nursing assistant had completed only the first step of the required two-step screening process.
Regional Director of Operations #440 confirmed that new employees should receive the complete two-step tuberculin skin test upon hire. She noted that the facility had not experienced any tuberculosis infections.
The incomplete testing represented a significant breakdown in infection control protocols. Tuberculosis remains a serious infectious disease that spreads through airborne droplets when infected individuals cough, sneeze, or speak. Healthcare workers without proper screening pose particular risks in congregate care settings where residents often have compromised immune systems.
The two-step tuberculin skin test exists specifically to identify individuals with latent tuberculosis infection who might not show positive results on a single test. The first test can boost immune response, making a second test more likely to detect existing infections that would otherwise go unnoticed.
Without complete screening, the facility could not determine whether these three employees carried tuberculosis infections that might spread to vulnerable residents. The 80-person census meant the entire resident population faced potential exposure from unscreened staff members.
State inspectors discovered the violations during a complaint investigation conducted on September 9. The findings indicated that basic infection prevention protocols had failed at multiple levels, from initial hiring procedures through ongoing compliance monitoring.
The housekeeper's case proved particularly concerning because her incomplete testing dated back nearly a year. For eleven months, she worked throughout the facility with only partial tuberculosis screening, potentially exposing residents and colleagues to undetected infection.
The nursing assistant's situation highlighted similar systemic failures. Despite working directly with residents for more than two months, she never received the second tuberculin skin test that might have revealed latent tuberculosis infection missed by the initial screening.
The licensed practical nurse's case represented the most serious breakdown. With no tuberculosis testing whatsoever, she provided direct patient care for seven months without any screening for a disease that could spread rapidly through a nursing home population.
Facility policy clearly outlined the screening requirements, stating that all employees must be tested for latent tuberculosis infection and active TB disease using tuberculin skin tests or blood assays, along with symptom screening, before beginning employment. The policy violations affected staff hired across different time periods, suggesting ongoing compliance problems rather than isolated oversights.
The inspection findings revealed that Ayden Healthcare's tuberculosis prevention program existed on paper but failed in practice. While the facility maintained policies requiring proper screening, it allowed multiple employees to work for months without completing the mandated testing protocols.
The Regional Director of Operations' acknowledgment that no tuberculosis infections had occurred at the facility did not address the fundamental problem: without proper testing, undetected infections could spread unnoticed until symptoms appeared or routine screening eventually identified them.
The three employees represented different job categories throughout the facility, indicating that the screening failures affected various departments and levels of patient contact. From direct nursing care to environmental services, unscreened workers potentially exposed residents during routine daily activities.
The violation occurred under complaint number 2612082, suggesting that concerns about infection control practices had prompted the state investigation that uncovered the tuberculosis screening deficiencies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ayden Healthcare of Oregon from 2025-09-09 including all violations, facility responses, and corrective action plans.