Federal inspectors observed the violation during a September complaint investigation at Azria Health Park Place. The incident involved a resident with dementia, a fractured right leg, and morbid obesity who required two-person assistance for toileting.
On September 8 at 2:18 PM, inspectors watched as Staff E removed the resident's soiled brief and sprayed cleansing foam onto the resident's abdominal fold and genital area. The nursing assistant provided intimate care, then rolled the resident onto her left side and removed a sling and soiled brief from underneath.
Staff E took a bottle of foam cleanser and sprayed it directly onto the resident's buttocks area. Using disposable wipes, the assistant cleaned the buttocks while Staff G helped position the resident and placed a clean brief. Staff G removed her gloves after the procedure ended.
Staff E never changed gloves or sanitized hands during the entire care episode.
Three days earlier, inspectors had observed proper infection control during similar care for the same resident. On September 5, Staff F had changed gloves and sanitized hands after touching contaminated surfaces and before handling clean supplies. That assistant rolled the resident onto her left side while Staff E removed soiled items and cleaned "a large amount of liquid stool" from the resident's lower back and buttocks.
Staff F removed gloves and sanitized hands after the procedure. Staff E properly bagged soiled linens and wheeled equipment back to the common area.
The resident's care plan, revised August 21, documented incontinence and the need for two-person assistance with toileting. Medical records showed diagnoses of dementia, a fractured right lower leg, and morbid obesity.
When questioned about expectations, facility leadership provided clear standards that staff had violated.
The Regional Nurse told inspectors on September 10 that she expected staff to change gloves "whenever the gloves were dirty."
The facility's Infection Preventionist was more specific. Gloves needed changing between contact with residents, during check-and-change procedures, and throughout care episodes, she said. Staff should change gloves "especially if the gloves were soiled."
Hand sanitizer could be used three to five times before hands required washing, the Infection Preventionist explained. Staff should disinfect equipment between each use.
The Director of Nursing echoed these requirements the next day, telling inspectors she expected glove changes "if soiled or in-between going from a dirty to clean area or task."
Facility policies supported these expectations. The infection control policy, revised in July 2014, aimed to "facilitate maintaining a safe, sanitary and comfortable environment" and prevent disease transmission.
A more recent Standard Precautions policy from September 2022 presumed that "all blood, body fluids and excretions may contain transmissible infectious agents." The policy required hand hygiene with alcohol-based rub or soap and water before and after resident contact.
Critically, the policy mandated hand hygiene "before moving from work on a soiled body site to a clean body site on the same resident" and after removing gloves.
Gloves must be "changed as necessary during the care of a resident to prevent cross-contamination from one body site to another such as when moving from a dirty site to a clean site," the policy stated.
The policy also required that resident care equipment be handled "in a manner to prevent transfer of microorganisms to other residents and the environment."
Staff E's failure to follow these protocols created potential for cross-contamination during intimate care of a vulnerable resident. The resident's dementia, incontinence, and mobility limitations made proper infection control especially critical.
The violation occurred despite clear facility policies and leadership expectations. Staff demonstrated they knew proper procedures just three days earlier during the same type of care for the same resident.
Federal inspectors cited the facility for failing to provide care in accordance with professional standards of practice. The violation affected multiple residents and carried minimal harm or potential for actual harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Azria Health Park Place from 2025-09-11 including all violations, facility responses, and corrective action plans.