CNA #413 confirmed to inspectors that she left Resident #6's room between providing catheter care and incontinence care with only one glove removed. She acknowledged that staff were not supposed to be in the hallway wearing soiled gloves and that she performed no hand hygiene before donning a clean glove.
The infection control violations extended beyond improper glove use. Staff placed clean washcloths directly on unclean overbed tables before beginning intimate care procedures, creating contamination risks during some of residents' most vulnerable moments.
During catheter care specifically, staff failed to follow basic cleanliness protocols. CNA #390 told inspectors that soiled items were never supposed to be placed on the floor, yet this was happening during care. The facility's own registered nurse, RN #398, confirmed that staff should use a barrier or wash basin rather than laying washcloths on unclean surfaces.
Multiple staff members demonstrated they understood the correct procedures when questioned by inspectors. CNA #383 confirmed that basins and clean washcloths were required for washing residents and that staff should never use the same part of a washcloth for cleaning around the catheter insertion site, the catheter itself, and other body parts.
RN #398 provided detailed explanation of proper catheter care technique. Staff were supposed to secure the catheter and clean in a circular motion from inner to outer areas, using a clean part of the washcloth with each stroke. Special care was required to ensure cleanliness of the catheter near the insertion site.
The registered nurse also confirmed that two bags should be readily available during care procedures — one for soiled disposable items and one for soiled linen. Personal protective equipment was supposed to be removed after care was completed, before leaving a resident's room.
Hand hygiene represented another breakdown in basic infection control. CNA #390 acknowledged that two bags should be prepared for waste disposal before beginning perineal or catheter care, and that PPE must always be removed before exiting resident rooms. Yet CNA #413's actions showed these protocols weren't being followed.
The facility's own policies, last reviewed as recently as January 2025, spelled out requirements that staff were violating. The Handwashing-Hand Hygiene policy required hand hygiene before and after putting on and taking off gloves, and after handling used linens or supplies. The policy specifically stated that wearing gloves did not replace proper hand hygiene.
Enhanced Barrier Precautions policy, also dated January 2025, required PPE removal inside the resident room after care activities were completed. Staff were placing contaminated equipment in hallways instead.
The Catheter Care policy emphasized cleaning the insertion site area thoroughly and removing all debris from around the catheter near the insertion site. For residents who were soiled or had bowel movements, the policy required incontinence care before catheter care to prevent contamination with feces.
Even the Incontinence Care policy, reviewed as recently as November 2025, required appropriate disposal of soiled linen — not placement on floors or unclean surfaces as was occurring.
CNA #390 told inspectors she understood that staff were supposed to make sure waste bags were ready before providing perineal or catheter care and that soiled items should never be placed on floors. The gap between what staff knew they should do and what they actually did during intimate care procedures represented a fundamental breakdown in infection control.
RN #398 confirmed during her interview that hand hygiene was always supposed to be performed with glove changes. Yet CNA #413's admission that she performed no hand hygiene before donning a clean glove after catheter care showed this wasn't happening.
The violations occurred during some of the most infection-prone care procedures residents receive. Catheter care and incontinence care require strict adherence to cleanliness protocols because residents are at heightened risk for urinary tract infections and other complications when proper techniques aren't followed.
State inspectors documented these failures as part of complaint investigation number 2618032. The findings revealed that despite having current policies outlining proper infection control procedures, Cedarwood Plaza staff were contaminating hallways with soiled gloves, placing clean supplies on dirty surfaces, and skipping hand hygiene during intimate resident care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedarwood Plaza from 2025-10-14 including all violations, facility responses, and corrective action plans.