The nurse placed the injection on a bedside table, sanitized his hands, and put on gloves before the resident asked to be repositioned. RN #3 then pressed the call light button and bed positioning controls before helping move the patient with a nursing assistant.
After repositioning, the same nurse retrieved the injection from the bedside table and administered the medication to the resident's abdomen using the same gloves he had worn while touching bed controls and moving the patient.
When confronted about the violation, RN #3 told inspectors: "I should have changed gloves after providing patient care and before giving the injection."
The nurse also pressed a gloved finger directly against the injection site after removing the needle, another breach of sterile technique. When asked about this practice, he said "since COVID there hasn't been a lot of quality control training."
The Director of Nursing confirmed the violations during the September 12 inspection, stating nurses "should always perform hand hygiene and change gloves when alternating between patient care to giving an injection."
She explained proper injection protocol requires placing a barrier on the table before setting items down, performing hand hygiene, donning gloves, cleaning the injection site, and using gauze or a Band-Aid if bleeding occurs rather than touching the site with contaminated gloves.
The infection control failures extended beyond the nursing staff.
During the same inspection, a nursing assistant emptied a resident's bedside urinal in the bathroom but failed to rinse it clean before placing it back by the patient's bed. Inspectors noted a small amount of urine remained in the bottom of the container and detected a urine odor.
When questioned about the practice, the Director of Nursing revealed a systemic problem: "Our facility doesn't have a way to rinse urinals in any resident bathrooms, so we don't do it."
The Centers for Disease Control requires healthcare workers to perform hand hygiene and change gloves before moving from contaminated areas to clean procedures on the same patient. The guidelines specifically mandate hand cleaning after touching patients or their surroundings and immediately after glove removal.
Federal inspectors determined the facility failed to maintain basic infection prevention and control practices, creating potential risk for cross contamination and infection transmission among all residents.
The violations occurred despite clear CDC recommendations that healthcare workers must change protective equipment when moving between different types of patient care activities, particularly when transitioning from general care to sterile procedures like injections.
RN #3's admission that quality control training had declined "since COVID" suggests the facility may have relaxed infection control oversight during the pandemic and failed to restore proper protocols.
The nursing assistant's failure to properly clean the urinal, combined with the facility's admission that resident bathrooms lack rinsing capabilities, indicates systemic infrastructure and training deficiencies that could affect hygiene standards throughout the building.
The inspection classified the violations as having "minimal harm or potential for actual harm" but noted the failures had the potential to impact all residents by placing them at risk for infection transmission.
Both incidents occurred within a 20-minute window during the morning inspection, suggesting these practices may be routine rather than isolated lapses in protocol.
The facility's infection control program is required under federal regulations to prevent the spread of communicable diseases and healthcare-associated infections among residents, many of whom have compromised immune systems due to age and underlying health conditions.
Proper glove changing between different care activities serves as a critical barrier preventing the transfer of pathogens from contaminated surfaces to sterile injection sites or between different residents.
The urinal cleaning failure represents another pathway for infection transmission, as improperly cleaned equipment can harbor bacteria and create odors that affect resident dignity and comfort.
Federal inspectors found these violations during a complaint investigation, meaning concerns about infection control practices at the facility prompted the unscheduled visit.
The nursing staff's acknowledgment of the violations and the Director of Nursing's detailed explanation of proper procedures suggest awareness of correct protocols, making the observed failures more concerning as they appear to represent lapses in implementation rather than lack of knowledge.
The facility now faces potential federal enforcement action for failing to maintain infection prevention and control standards that protect vulnerable nursing home residents from preventable infections and cross contamination.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Payette Healthcare of Cascadia from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Payette Healthcare of Cascadia
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