The violations occurred during meal delivery to residents in contact isolation rooms, where patients with infectious conditions require staff to wear gowns and gloves to prevent spreading disease.
CNA 4 was observed at 1:09 p.m. placing a lunch tray on top of a contact isolation cart outside one resident's room. She put on an isolation gown but no gloves before entering the room of Resident 4.
Inside the room, the aide used her bare hands to move the resident's bedside table and remove lids from meal containers. She then placed those contaminated lids back on the isolation cart outside the room and washed her hands.
But after performing hand hygiene, CNA 4 grabbed the same contaminated lid from the cart and placed it on the lunch cart. She then picked up another lunch tray and delivered it to Resident 7 without washing her hands again.
Ten minutes later, inspectors watched the same aide enter another contact isolation room to serve Resident 6. She wore an isolation gown but no gloves.
CNA 4 touched the resident's bedside table with her bare hands, adjusted the bed height, and repositioned the patient's blanket. She then fed Resident 6 without performing any hand hygiene.
During questioning, CNA 4 acknowledged she knew the policy required both gowns and gloves for contact isolation rooms. When asked if she wore gloves while dropping off lunch trays in isolation rooms, she said no, "only when working with the residents."
The aide admitted she failed to use proper personal protective equipment and hand hygiene practices when entering contact isolation rooms.
Another infection control violation involved expired hand sanitizer during wound care. Inspectors observed a nurse treating a resident's wound using hand sanitizer that had expired in February 2024.
The nurse was seen applying the expired sanitizer to her hands after removing an old dressing and before throwing away unused, contaminated gauze.
The Director of Nursing acknowledged the expired hand sanitizer should have been discarded. She confirmed proper protocol requires performing hand hygiene after removing soiled dressings and disposing of any unused supplies that enter a resident's room.
Contact isolation protocols exist to prevent the spread of infectious diseases like MRSA, C. difficile, and other antibiotic-resistant organisms that can be deadly to vulnerable nursing home residents.
The DON told inspectors that entering contact isolation rooms requires hand washing or sanitizing plus wearing both gowns and gloves. Staff must perform hand hygiene again after leaving isolation rooms.
She acknowledged the violations documented by federal inspectors.
The facility administrator was also made aware of the findings and acknowledged them during the September inspection.
Federal regulations require nursing homes to maintain infection prevention and control programs to protect residents from acquiring and transmitting communicable diseases. Facilities must train staff on proper hand hygiene and use of personal protective equipment.
Contact isolation residents are among the most vulnerable in nursing homes, often harboring infections that can spread rapidly through a facility if proper precautions aren't followed.
The inspection found minimal harm occurred, affecting few residents. But the violations demonstrate systematic failures in basic infection control practices that could have serious consequences for patient safety.
CNA 4's actions created a direct pathway for transmitting infectious organisms from isolated patients to other residents through contaminated surfaces and inadequate hand hygiene.
The use of expired hand sanitizer during wound care further compromised infection control, potentially exposing both the treating nurse and patient to additional risks.
Park Vista at Morningside must now develop corrective action plans to address the infection control deficiencies and ensure staff comply with contact isolation protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Vista At Morningside from 2025-09-16 including all violations, facility responses, and corrective action plans.