The incident occurred on October 7 at Accel At Crystal Park, where federal inspectors found the facility failed to follow infection prevention protocols during intravenous medication administration.
At 8:01 a.m., inspectors observed IV tubing in Resident #5's room without an end cap, hanging nearly to the floor. The tubing was connected to a new bag of meropenem, a powerful antibiotic used to treat serious infections. The tubing bore no date indicating when it was hung.
Two empty bags of meropenem and a discarded white syringe cap sat in the room's trashcan alongside a small amount of clear liquid.
Twenty-two minutes later, LPN #1 entered the room where Resident #5 lay with a PICC line in their right arm. The nurse picked up the IV tubing and pole, bringing it closer to the resident.
Wearing only gloves, the nurse wiped the contaminated tubing end with an alcohol prep pad, then wiped the PICC hub and connected the tubing to the resident's central line. At 8:28 a.m., the nurse started the antibiotic infusion.
The facility's own policy, revised in October 2024, requires intermittent IV sets used multiple times within 24 hours to have "a new single use sterile cap on the end of the set after each intermittent use." The policy also mandates labeling with date, time hung, replacement date, and staff initials.
LPN #1 violated both requirements.
The nurse also failed to wear a gown during the procedure, despite facility policy requiring enhanced barrier precautions for residents with central lines. The March 2025 policy specifically lists "central line" under device care requiring enhanced protection to prevent transmission of multidrug-resistant bacteria.
When questioned at 8:00 a.m., LPN #1 said they had "just set up" the antibiotic for the resident's return. An hour later, the nurse admitted uncertainty about IV tubing change frequency at the facility, stating it was their fifth day of work.
"They stated IV tubing was usually changed every 24 hours," inspectors noted. "LPN #1 stated they did not change Resident #5's IV tubing and it had no date."
The nurse demonstrated additional gaps in infection control knowledge. When asked about enhanced barrier precautions at 9:00 a.m., LPN #1 said they "were not sure if the resident was supposed to be on EBP and did not know what it meant."
One minute later, the nurse acknowledged the infection control violation: "They stated the IV tubing was supposed to have an end cap for infection control. They stated Resident #5's tubing did not have an end cap."
LPN #1 explained they had discarded a white cap from a normal saline syringe that was initially on the tubing.
Resident #5 had been receiving the antibiotic meropenem every eight hours since September 20, according to physician orders, to treat atherosclerosis with ulceration in their right leg. The resident's August assessment showed they had undergone major orthopedic surgery and required central IV access.
The traveling director of nursing told inspectors that 21 residents in the facility were on enhanced barrier precautions.
At 12:37 p.m., the director of nursing clarified proper protocol: IV tubing used once in 24 hours should be discarded after use. Tubing used for multiple administrations should have an end cap and be discarded after 24 hours, with proper labeling including dates, times, and staff initials.
The director confirmed that enhanced barrier precautions require both gown and gloves.
The violation occurred despite clear written policies. The facility's administration set change policy, updated just months before the incident, explicitly addresses intermittent IV use. The enhanced barrier precautions policy, revised in March 2025, specifically covers central line care.
Federal inspectors classified the violation as having potential for minimal harm, but the breach of multiple infection control protocols created unnecessary risk for a resident receiving treatment through a central line.
Resident #5 continued receiving the antibiotic infusion despite the contamination risk from the floor-exposed tubing and the nurse's failure to follow protective equipment requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accel At Crystal Park from 2025-10-16 including all violations, facility responses, and corrective action plans.