The incident at Timber Springs Transitional Care occurred during morning medication rounds on September 10, when federal inspectors were observing infection control practices. RN #3 was preparing medications when the tablet dropped from the cup onto the cart's top surface.
She put on a glove, retrieved the tablet from the cart, and placed it back in the medication cup. She then continued preparing and administering medications to Resident #50.
When questioned 20 minutes later, RN #3 acknowledged that cross-contamination may have occurred when the tablet contacted the cart surface. She told inspectors she had sanitized the cart at the beginning of her shift but had not cleaned it immediately before preparing medications.
The medication safety violation was one of three infection control failures documented during the September complaint investigation. Inspectors found the facility failed to implement proper infection prevention practices for two residents, creating potential for cross-contamination, infection, and life-threatening complications.
The same morning, inspectors discovered an open Rock Star energy drink and an open bag of pretzels stored in the third drawer of a medication cart in the 220 hall. LPN #3 stated that food should not be stored in medication carts and was unsure who had placed the items there.
The facility's Director of Nursing confirmed that no food or beverages should be stored in medication carts.
The most serious violation involved the care of Resident #2, who had been readmitted with multiple life-threatening conditions including end-stage heart failure, cirrhosis of the liver, and immunodeficiency. The resident required a Left Ventricular Assist Device, a mechanical pump that helps the heart circulate blood.
The resident's care plan, initiated June 30, specifically directed staff to wear gowns and gloves for high-contact personal care activities due to the LVAD's presence. The facility's own LVAD Management Manual documented that dressing changes are sterile procedures requiring masks, surgical caps, and sterile fields for dressing materials.
On September 11 at 11:54 AM, LPN #4 entered Resident #2's room and retrieved the dressing package from the dresser. She placed it directly on the bed without any barrier underneath.
She then placed her gloves on top of the packaging and put on her gown. The nurse opened the dressing materials without establishing a sterile field, violating the facility's own protocols for the life-sustaining device.
LPN #4 helped Resident #2 put on a surgical mask before placing her own mask. She removed the soiled dressing, discarded it along with her gloves, performed hand hygiene, and continued the dressing change using clean gloves rather than sterile ones.
When inspectors asked whether the procedure was sterile or clean, LPN #4 said it was a clean procedure.
Twenty-one minutes later, the Director of Nursing told inspectors that LPN #4 should have placed a barrier between the bed and the dressing materials. The DON confirmed that the procedure should have been performed using sterile technique, not the clean technique actually used.
For patients with LVADs, infection represents a potentially fatal complication. The devices require surgical implantation and create a permanent opening in the chest where infection can enter the bloodstream and travel directly to the heart.
The facility's own manual recognized these risks by requiring sterile procedures, yet staff performed the dressing change in a manner that could introduce bacteria to the surgical site.
Federal inspectors cited the facility for failing to provide and implement an infection prevention and control program. The violations affected few residents but created minimal harm or potential for actual harm, according to the inspection report.
The September 12 complaint investigation documented systematic breakdowns in basic infection control practices across medication administration, storage, and sterile procedures. Each violation represented a failure to follow the facility's own policies designed to protect vulnerable residents from preventable infections.
Resident #2 continues to require the LVAD to survive, making proper sterile technique during dressing changes critical to preventing life-threatening complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Timber Springs Transitional Care from 2025-09-12 including all violations, facility responses, and corrective action plans.
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