Federal inspectors observed the violations twice on November 3 at Carriage Square Rehab and Healthcare Center during intimate care of Resident #3, who required complete assistance with personal hygiene and was always incontinent of bowel and bladder.
At 10:58 that morning, inspectors watched CNA A clean down the left side of the resident's perineal area with a wet wipe, fold the contaminated wipe, then use the same folded wipe to clean down the right side. After finishing the perineal care, the nursing assistant put a new incontinence brief on the resident while still wearing the same gloves used during cleaning.
The scene repeated 36 minutes later. At 11:34 a.m., inspectors again observed CNA A and CNA B providing perineal care to the same resident. CNA A used a wet wipe to clean the right side of the perineal area, folded the contaminated urine-soaked wipe, then used the folded portion to clean the right side again. The assistant then put a clean brief on the resident without changing gloves.
When questioned about the practices, CNA A defended the technique. During an interview at 11:43 a.m., the assistant said when performing perineal care, "he/she cleans down one side of the perineal area then will fold the wipe and clean the other side of the perineal area with the same wipe." The assistant added that after using the folded wipe on both sides, "he/she will then get a new wipe to clean the middle of the resident's perineal area."
The resident receiving this care was completely dependent on staff for emotional, physical, and psychosocial needs, according to care plan documentation revised in June. The person's care plan specifically noted a potential for skin impairment due to bowel and bladder incontinence, making proper hygiene procedures critical.
Other staff members understood the correct procedures. Certified Medication Technician A told inspectors that wipes should be "used once then discarded" during perineal care, and that staff should "change gloves before getting a resident dressed" after performing intimate care.
CNA B, who was present during the second observed violation, confirmed the proper protocol. During a 2:04 p.m. interview, the assistant said "wipes are to be used once and then thrown away when performing perineal care on residents" and that "gloves are to be changed after cleaning a resident and before putting clean clothes on a resident."
The Director of Nursing also confirmed the facility's policy during a 2:40 p.m. interview. The DON said "staff are to use a wipe once when providing perineal care then get a new wipe to continue cleaning the resident, using each wipe once."
The violations occurred despite clear facility policies requiring single use of cleaning materials and glove changes between contaminated and clean tasks. The inspection was conducted in response to complaints about care practices at the facility.
Resident #3's quarterly assessment from earlier this year documented complete incontinence and total dependence on staff for personal care activities. The person's care plan emphasized the need for nursing staff assistance with all personal hygiene tasks due to the resident's functional limitations.
The contaminated glove and wipe reuse created potential for cross-contamination during intimate care of a vulnerable resident who relied entirely on staff for proper hygiene. Federal inspectors classified the violations as having minimal harm or potential for actual harm, affecting some residents at the facility.
The inspection report documented two separate complaint intakes related to the care practices observed, suggesting ongoing concerns about hygiene protocols at Carriage Square Rehab and Healthcare Center.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carriage Square Rehab and Healthcare Center from 2025-11-03 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Carriage Square Rehab and Healthcare Center
- Browse all MO nursing home inspections