The September inspection at Nexus at Alton revealed multiple infection control violations during care for a resident with chronic respiratory failure who required enhanced barrier precautions due to wound colonization and his tracheostomy status.
Licensed Practical Nurse V4 entered the resident's room on September 17 to assist with tracheostomy care. The resident, identified as R4, performs most of his own care but needs some assistance from staff.
V4 washed her hands and put on gloves before gathering supplies from multiple drawers. But she changed gloves without washing her hands between glove changes - a violation that occurred repeatedly during the 20-minute procedure.
The resident's tracheostomy collar showed green and brown drainage on the left side. Dried drainage covered the left side of his neck and the area under his neck. R4 began cleaning the drainage himself using gauze pads dipped repeatedly in sterile saline.
V4 removed her gloves, washed her hands, and put on sterile gloves to attach a new tracheostomy tie and collar. But when she removed the sterile gloves to put on non-sterile ones, she again skipped hand washing.
That's when the most serious contamination occurred.
R4 was trying to remove his tracheostomy collar from behind his neck when V4 used her gloved hands to touch her long hair and move it behind her back. With those same contaminated gloves, she then helped the resident remove his collar and attached the right tracheostomy tie.
V4 changed gloves again without hand hygiene, placed a gauze pad under the tracheostomy tube, and applied Nystatin powder to the resident's neck and upper chest with the same gloves.
The violations didn't end there. V4 never wore a personal protective gown despite facility policy requiring gowns for high-contact care activities involving tracheostomies. She failed to provide a sterile field for supplies and didn't clean the pulse oximetry device after using it on the resident.
Most concerning to infection control experts, V4 never encouraged the resident to wash his hands before, during, or after the procedure, even though he was handling his own contaminated tracheostomy equipment.
Director of Nurses V2 acknowledged the multiple failures when interviewed five days later. She confirmed that V4 should have washed her hands between glove changes, worn a gown, and followed sterile procedures. The resident should have been offered hand hygiene and not allowed to reuse gauze pads, she said.
The facility's own policies clearly outlined the required procedures. The Enhanced Barrier Precautions policy, dated October 2023, requires staff to wear gowns and gloves for high-contact resident care involving tracheostomies and ventilators.
The Hand Hygiene policy mandates hand washing before and after any procedure and before and after resident contact. The Tracheostomy Care Policy requires staff to maintain sterility of the dominant hand and arrange contents on a sterile field.
The Equipment Cleaning policy specifies a five-step process for cleaning monitors and other devices between residents, including using bleach wipes and allowing proper contact time for disinfection.
None of these protocols were followed during R4's care.
The resident had been admitted with chronic respiratory failure and hypoxia, conditions that make proper infection control critical. His physician had ordered enhanced barrier precautions specifically because of colonization related to his wounds, colostomy, and tracheostomy.
Tracheostomy patients face elevated infection risks because the procedure bypasses the body's natural defense mechanisms in the upper respiratory tract. Contaminated equipment or improper hand hygiene can introduce dangerous bacteria directly into the respiratory system.
The inspection occurred in response to a complaint and focused on infection control practices throughout the facility. Inspectors reviewed five residents' care and found violations affecting one of them.
Federal regulators classified the harm level as minimal, but the potential consequences of contaminating sterile procedures for medically fragile residents can be severe. Respiratory infections in patients with chronic conditions often lead to hospitalization or worse outcomes.
The facility now faces federal oversight to correct its infection control deficiencies and retrain staff on proper procedures for residents requiring enhanced precautions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nexus At Alton from 2025-09-30 including all violations, facility responses, and corrective action plans.