SMP Health - St Raphael: Infection Control Gaps - ND
Federal inspectors documented these infection control failures at SMP Health - St Raphael during a September complaint investigation, finding staff violated basic hygiene protocols that the facility's own policies required.
The violations occurred despite clear facility guidelines. The nursing home's glove usage policy, revised in November 2018, stated that "once gloves are contaminated, they must be changed before touching clean items or proceeding to perform clean procedure." The policy also required hand hygiene "prior to gloving and after removing gloves."
On September 23 at 9:39 a.m., inspectors watched Nurse #1 perform a dressing change for Resident #73. The nurse put on protective equipment and entered the room, then removed a soiled abdominal pad from the resident's left hip.
Without changing gloves, the nurse cleaned the wound area, placed a new dressing, and applied tape. Only after completing the entire procedure did the nurse remove the gown and gloves and wash hands.
The same afternoon, inspectors observed two certified nursing assistants caring for Resident #16. CNAs #2 and #5 transferred the resident from wheelchair to bed using a mechanical lift, both wearing gowns and gloves.
CNA #2 then performed perineal care after the resident had a soft bowel movement. With the same gloves that had contacted feces, the aide reached into a container of ointment and applied it to the resident's bottom.
The contamination spread continued. Still wearing the same gloves, CNA #2 fastened a new brief, pulled up the resident's pants, opened a drawer to get a bandana, and placed it near the resident's mouth. The aide then plugged in a pump, tied a garbage bag, lowered the bed, turned on the television, removed a pillowcase from the resident's neck pillow, and tied another garbage bag.
Only after touching all these surfaces did CNA #2 remove the gloves and perform hand hygiene.
The facility's hand hygiene policy, updated as recently as September 2023, specifically required hand cleaning "after handling contaminated objects" and "before and after handling clean or soiled dressing." The policy emphasized that hand hygiene was "an effective method for preventing the spread of pathogens, such as bacteria and viruses, which cause infections."
When questioned the next day, Administrative Nurse #4 confirmed that staff should remove gloves and perform hand hygiene after removing soiled dressings and after perineal care.
The inspection found these failures affected two of seven residents observed during care procedures. Federal investigators determined the violations created "minimal harm or potential for actual harm" but noted that failure to follow proper infection control "has the potential to spread infection throughout the facility."
Both incidents violated federal requirements that nursing homes provide and implement an infection prevention and control program. The violations occurred during routine care procedures when proper hygiene protocols are most critical for preventing the spread of bacteria and viruses among vulnerable residents.
The inspection documented how contaminated gloves became vehicles for spreading pathogens from wound drainage and fecal matter to clean medical supplies, resident belongings, and room surfaces. Each surface the nursing assistant touched with contaminated gloves - the ointment container, drawer handles, television controls, pillowcases - became a potential source of infection for the resident and future patients.
The nursing home's own policies recognized these risks, requiring glove changes "before touching clean items" and hand hygiene after any contact with contaminated materials. Staff interviews confirmed they understood these requirements.
Yet the observed care showed systematic failures to follow these basic infection control measures, creating exactly the conditions the policies were designed to prevent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Smp Health - St Raphael from 2025-09-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SMP HEALTH - ST RAPHAEL in VALLEY CITY, ND was cited for violations during a health inspection on September 24, 2025.
The violations occurred despite clear facility guidelines.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.