Federal inspectors observed CNA #525 on October 6th as she moved from room to room at Franciscan Care Center Sylvania, setting up meal trays and assisting residents without performing hand hygiene between any contacts. The violation affected eight of eight residents observed during the meal service at the 70-bed facility.
The nursing assistant began by retrieving a meal tray from the hallway cart and delivering it to Resident #81's bedside table. She opened silverware packages, removed lids from bowls and plates, and inserted a straw into a cup. She never washed her hands.
CNA #525 returned to the hallway cart and retrieved another tray for Resident #51, touching the bedside table as she set up the meal. Again, no hand hygiene.
The pattern continued with Resident #58. But this time, the nursing assistant brought the resident's dirty water cup out of the room and placed it directly on top of the meal tray cart in the hallway where clean trays were stored.
Without washing her hands after handling the contaminated cup, CNA #525 closed the meal cart and walked to the nurses' station. She obtained ice from the cooler used to serve water to residents, filled a cup, and delivered it to a visitor.
The nursing assistant then went to a supply room for straws, delivered them to two residents, and placed the remaining handful on top of the meal tray cart where she had earlier set the dirty water cup.
When she reached Resident #53, the violation became more direct. The resident requested that CNA #525 cut up her food into bite-sized pieces. The nursing assistant had just touched the resident's bedside table, wheelchair, and picked up a piece of paper from the floor. Without washing her hands, she used the silverware from the meal tray to cut the food that the resident would eat.
The contamination spread further with Resident #34. CNA #525 assisted with cleaning fluid from the floor using paper towels, then removed a full trash bag from the waste container. Immediately afterward, without hand hygiene, she set up the resident's meal tray, touching two cups and inserting straws into beverages the resident would consume.
She carried the trash bag to the soiled utility room, returned to the meal cart, touched her face, and retrieved the final tray for Resident #54. She opened a soda can, inserted a straw into a cup, opened silverware packages, and moved the plate closer to the resident.
During the entire 20-minute observation period, CNA #525 never performed hand hygiene once.
When inspectors interviewed the nursing assistant immediately after the meal service at 12:47 PM, she confirmed every detail of their observations. She acknowledged she should have washed her hands between residents, after cleaning the floor, and after handling trash.
The facility's own policy, dated September 16th and titled "Hand Hygiene," required all staff to perform proper hand hygiene to prevent infection spread to staff, visitors, and residents. The policy specifically mandated hand hygiene between resident contacts and after handling contaminated objects.
CNA #525 violated both requirements repeatedly. She moved between eight residents without washing her hands between any of them. She handled contaminated objects including dirty water cups, floor spills, trash bags, and soiled surfaces, then immediately touched clean meal service items, beverages, and food that residents consumed.
The nursing assistant placed a dirty water cup on the same surface where clean meal trays were stored. She handled trash, then touched drinking cups. She cleaned bodily fluids from the floor, then set up meal trays without washing her hands.
Most concerning, she cut food into bite-sized pieces for Resident #53 using silverware after touching contaminated surfaces, creating direct contamination of food the resident would eat.
Federal inspectors classified this as an infection prevention and control violation with minimal harm or potential for actual harm. The failure affected every resident observed during the meal service, representing more than 11 percent of the facility's census.
The violation occurred during a complaint inspection, suggesting someone had raised concerns about infection control practices at the facility. The detailed observation revealed systemic failure to follow basic hygiene protocols during one of the most routine daily activities in nursing home care.
Eight residents received meals contaminated through repeated cross-contamination from dirty surfaces, trash, and bodily fluids. The nursing assistant acknowledged she knew the requirements but failed to follow them during the entire meal service period inspectors observed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Franciscan Care Ctr Sylvania from 2025-11-13 including all violations, facility responses, and corrective action plans.