The October inspection at Moran Nursing and Rehabilitation Center found staff failing to follow basic infection control protocols for residents with catheters, who require enhanced barrier precautions to prevent the spread of dangerous bacteria.
CNA #20 admitted multiple safety violations during her interview with inspectors. She acknowledged that Resident #8 was on enhanced barrier precautions but said she "was not sure when to wear a gown when providing care to the resident." The aide also confessed she failed to change her gloves after wiping the resident during incontinence care.
"She was nervous," the inspection report stated, documenting the aide's explanation for not following required safety protocols.
The facility places all residents with catheters on enhanced barrier precautions, a heightened infection control protocol designed to prevent the transmission of multidrug-resistant organisms. These residents face increased risk of serious infections that can spread to other vulnerable patients.
Enhanced barrier precautions require staff to wear both gloves and gowns during any personal care. The protocols exist because catheter patients are at high risk for carrying dangerous bacteria like carbapenem-resistant Enterobacteriaceae, which can cause life-threatening infections and resist most antibiotics.
The Quality Assurance and Infection Prevention Nurse confirmed the facility's policy during her interview with inspectors. Staff "should wear gloves and a gown when personal care was provided" to residents on enhanced barrier precautions, she stated. She added that staff "should change gloves if they became soiled and could change gloves at any time."
Multiple managers told inspectors they expected staff to follow proper infection control procedures, yet the violations occurred under their supervision.
The Assistant Director of Nursing said staff "were expected to change gloves if they became soiled and before placing a clean brief on the resident." She confirmed that "all residents with catheters were on EBP, and staff were expected to wear a gown and gloves when incontinence care was provided."
But when asked who monitored whether staff actually wore the required protective equipment, the Assistant Director of Nursing said she "was not sure who monitored incontinence care."
The Director of Nursing repeated the facility's policies during her interview but acknowledged gaps in oversight. She stated that residents with catheters "were on EBP, and staff were expected to wear a gown and gloves when incontinence care was provided." She said gloves "should be changed when they were visibly dirty" and that she personally would change them "before putting a clean brief on a resident."
The Director of Nursing placed responsibility for monitoring compliance on the Quality Assurance and Infection Prevention Nurse, saying she "should monitor to ensure staff followed infection control protocol when providing incontinence care."
Facility Administrator told inspectors she "expected staff to wear a gown and gloves if a resident was on EBP and to change gloves between dirty and clean areas." She said both the Quality Assurance and Infection Prevention Nurse and the Director of Nursing "should monitor staff to ensure they followed proper infection control procedures."
The inspection revealed a troubling pattern: while administrators and nursing supervisors could recite the facility's infection control policies in detail, front-line staff were confused about basic requirements and admitted skipping safety protocols.
CNA #20's admission that she was "nervous" about following proper procedures suggests inadequate training or supervision. Her uncertainty about when to wear protective gowns indicates staff may not understand the serious health risks posed by enhanced barrier precaution violations.
The Quality Assurance and Infection Prevention Nurse told inspectors that she, along with the Assistant Director of Nursing, unit managers, and Director of Nursing, "monitored staff for proper hand hygiene and infection control." Yet this monitoring system failed to prevent or detect the violations that inspectors discovered.
Infection control failures in nursing homes can have devastating consequences. Residents with catheters already face elevated infection risks, and improper protective equipment use can spread dangerous bacteria to other vulnerable patients throughout the facility.
The inspection documented these violations as causing "minimal harm or potential for actual harm" affecting "few" residents. However, infection control breaches can escalate quickly in nursing home environments where elderly residents have compromised immune systems and multiple chronic conditions.
Federal inspectors found the facility failed to ensure staff followed established infection prevention and control procedures, violating requirements that nursing homes maintain programs to investigate, control, and prevent infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Moran Nursing and Rehabilitation Center from 2025-10-23 including all violations, facility responses, and corrective action plans.
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