The violation occurred at Deerbrook Skilled Nursing and Rehab Center during a complaint investigation completed October 27. Federal inspectors observed the nursing assistant, identified as CNA A, performing perineal care on Resident #1 but failing to follow basic infection control protocols afterward.
CNA A told inspectors she "got nervous" and forgot to perform hand hygiene before leaving the resident's room. She acknowledged keeping the used gloves in her pocket, admitting this practice was "not hygienic" and "not an encouraged habit."
The assistant had checked the doorway for extra large gloves but claimed she didn't know they were available. She confirmed she cleaned the resident's penis by wiping with a cleansing cloth twice, following training she received when she started working at the facility several months earlier.
When questioned about the risks, CNA A demonstrated clear understanding of infection control principles. She explained that germs from hands can transfer to items that residents might touch, potentially causing infections. The facility's Director of Nursing confirmed that elderly residents and those with histories of urinary tract infections are particularly susceptible to such complications.
The DON stated she expected nursing staff to change gloves and sanitize or wash hands "to prevent infection as much as possible" when moving from clean to dirty areas during intimate care. She suggested the CNAs "may have been rushing through their work" and failed to perform hand hygiene as expected.
The facility's own perineal care policy, revised in December 2011, explicitly outlines the infection control requirements CNA A ignored. The policy states its purpose is "to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition."
For male residents, the policy requires washing the perineal area starting with the urethra and working outward. Step 12 mandates removing gloves and discarding them into a designated container, followed by thorough hand washing and drying. Step 13 requires putting on clean gloves before placing a new brief. The final steps again require removing gloves and washing hands thoroughly.
CNA A violated multiple steps in this established protocol. She neither discarded her gloves in a designated container nor washed her hands after the intimate care procedure. Instead, she pocketed the contaminated gloves and continued her duties.
The nursing assistant had received inservices on both infection control and perineal care for male and female residents. Despite this training, she failed to implement the most basic safeguards designed to protect vulnerable residents from preventable infections.
Her admission that she understood the infection risks makes the violation particularly concerning. She correctly identified that germs from unwashed hands could contaminate surfaces and potentially infect residents who touch the same items later.
The DON emphasized that proper hand hygiene and glove changes are essential for preventing urinary tract infections, especially among the facility's elderly population. Residents with long histories of UTIs face heightened vulnerability to complications from poor infection control practices.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the incident reveals a breakdown in basic infection prevention protocols that form the foundation of safe nursing home care.
The violation occurred during a complaint investigation, suggesting concerns about care practices had already been raised. The specific nature of the complaint that triggered the inspection was not detailed in the available documentation.
CNA A's acknowledgment that keeping gloves in pockets was unhygienic indicates awareness of proper protocols, making her failure to follow them more troubling. Her nervousness, while understandable, cannot excuse compromising resident safety through poor infection control.
The facility's detailed policy demonstrates clear standards for perineal care and infection prevention. The gap between written protocols and actual practice suggests inadequate supervision or enforcement of these critical safety measures.
Residents receiving intimate care are among the most vulnerable to infections. Their dignity and health depend on nursing staff consistently following established protocols, regardless of time pressures or personal anxiety.
The Director of Nursing's suggestion that staff were "rushing through their work" points to systemic issues beyond individual performance failures. Adequate staffing and time allocation are essential for maintaining infection control standards during intimate care procedures.
CNA A continues working at the facility while managers address the violation through their corrective action process.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Deerbrook Skilled Nursing and Rehab Center from 2025-10-27 including all violations, facility responses, and corrective action plans.
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