The CNA, identified only as "CNA A" in inspection records, told investigators she knew she should perform hand hygiene before leaving Resident #1's room but got nervous and didn't do it. When pressed about the risks, she acknowledged that "germs from hands can get onto items touched and a resident could get infected if they touch the same items."
The violation occurred during perineal care, one of the most infection-prone activities in nursing homes. Federal inspectors documented the hand hygiene failure as part of a broader pattern of staff rushing through their work without following basic infection control protocols.
Director of Nursing acknowledged the problem during her October 27 interview with inspectors. She said she expected nursing staff to change gloves and sanitize or wash hands "to prevent infection as much as possible any time they are working from a clean area to a dirty area such as during peri care."
The DON told inspectors the CNAs "may have been rushing through their work and did not perform hand hygiene as she expected." She specifically cited preventing urinary tract infections as a key reason for proper hand hygiene, noting that "residents who have a long history of UTIs, and the elderly population are examples of residents who are susceptible to UTIs."
Facility policies obtained during the inspection show staff knew the requirements. The perineal care policy, revised in December 2011, explicitly requires staff to "wash and dry your hands thoroughly" before putting on gloves, then again after removing gloves and before putting on clean gloves to place a new brief.
The policy lists three purposes for the procedure: "to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition."
But knowing the policy and following it proved to be different things at Deerbrook.
The facility had implemented Enhanced Barrier Precautions in April 2024, designed specifically to prevent transmission of multidrug-resistant organisms. The policy requires gowns and gloves during "high-contact resident care activities" including dressing, transferring, changing briefs, and device care.
Enhanced Barrier Precautions apply to residents with wounds or indwelling medical devices, even if they're not known to be infected with resistant organisms. The policy specifically covers chronic wounds like pressure ulcers, diabetic foot ulcers, and unhealed surgical wounds.
Yet staff weren't consistently following even basic handwashing protocols, let alone the enhanced precautions.
The inspection revealed a fundamental disconnect between written policies and actual practice. While the facility had detailed procedures for everything from mechanical lift disinfection to urinary catheter care, staff were skipping the most basic step in infection prevention.
Hand hygiene failures in nursing homes create cascading risks. When staff move from resident to resident without proper handwashing, they can transmit bacteria, viruses, and resistant organisms throughout the facility. The elderly residents at facilities like Deerbrook are particularly vulnerable due to compromised immune systems and underlying health conditions.
The DON's comment that staff were "rushing through their work" points to a systemic issue beyond individual compliance. When facilities operate with insufficient staffing or unrealistic time pressures, basic safety protocols often get sacrificed for speed.
CNA A's admission that she got "nervous" about hand hygiene suggests either inadequate training or workplace conditions that make staff anxious about taking time for proper procedures. Her accurate understanding of infection risks makes the violation more troubling, not less.
The October complaint inspection found the facility failed to meet federal standards for infection prevention and control. The violation affected "some" residents and carried a designation of "minimal harm or potential for actual harm."
But minimal harm designations can be misleading in infection control cases. A single hand hygiene failure might seem minor, but when multiplied across shifts, staff, and residents, the cumulative risk becomes substantial.
Federal inspectors classified the violation under F-tag 880, which requires facilities to establish and maintain an infection prevention and control program. The tag specifically mandates that facilities follow accepted standards of practice, including proper hand hygiene.
The inspection narrative cuts off mid-sentence while describing lift disinfection procedures, suggesting additional violations may have been documented. The complaint-driven inspection focused on specific concerns raised about the facility's practices.
For residents and families at Deerbrook, the findings raise questions about what other basic safety measures might be getting skipped when staff feel rushed or nervous. Hand hygiene represents the foundation of infection control in healthcare settings.
When that foundation cracks, everything else becomes more dangerous.
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.
Additional Resources
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