The September incident at Continuing Healthcare of Cuyahoga Falls violated the facility's own infection control policies and exposed residents to unnecessary contamination during vulnerable moments of care.
Resident 18 was fully aware of what was happening. The quarterly assessment showed they understood their surroundings but depended completely on staff for toileting and experienced frequent incontinence of both bowel and bladder.
State inspectors watched the 2:35 p.m. care routine unfold on September 25. Certified nursing assistants 364 and 373 had gathered their supplies beforehand, which seemed efficient. They performed hand hygiene and put on gloves before entering the room.
Then the problems began.
The assistants moved a bedside table next to the bed and set down their supplies directly on its surface. No cleaning. No barrier. A basin, pack of wipes, towel and multiple washcloths all made contact with whatever had been on that table before.
During the actual perineal care, CNA 364 took the pack of wipes from the contaminated bedside table and placed them directly on top of the resident's bed. The supplies that had touched the dirty table surface were now in direct contact with where the resident slept.
Before turning the resident to their right side, CNA 364 removed their gloves and put on a new pair. No hand washing in between.
When inspectors interviewed CNA 364 twenty-one minutes later, the assistant confirmed exactly what had been observed. No dispute about the facts.
The facility's own perineal care policy, updated in December 2023, specifically requires care "in a manner that reduces the risk of infection." It states that soiled gloves should be removed before applying a clean brief, followed by hand hygiene before putting on new gloves.
The infection control violations extended beyond perineal care.
Resident 52 had been admitted with a complex medical history including sepsis, cognitive impairment, schizoaffective disorder, diabetes and chronic lung disease. They required moderate to maximal assistance with daily activities and had an active wound on their left ankle.
The physician had ordered the ankle wound cleaned with normal saline and dressed with dry dressing every shift and as needed. Proper wound care becomes critical for residents with diabetes and a history of sepsis.
On September 29, Licensed Practical Nurse 350 prepared to change Resident 52's ankle dressing at 3:00 p.m. The nurse gathered supplies and performed hand hygiene before starting, following proper initial protocol.
But like the nursing assistants four days earlier, LPN 350 set all the wound care supplies directly onto the bedside table without cleaning it first or placing any barrier underneath.
The supplies that would touch an open wound made contact with whatever bacteria, medications, food residue or other contaminants had accumulated on that table surface.
When questioned five minutes after completing the procedure, LPN 350 acknowledged the bedside table had not been cleaned and no barrier had been placed before setting supplies on it.
The facility's wound care policy from June 2019 requires staff to "follow general infection control principles during dressing changes." Setting sterile supplies on contaminated surfaces violates basic infection control.
Both violations occurred during a complaint investigation numbered 2624366. The state classified the harm level as minimal, affecting some residents rather than all.
For Resident 18, who remained cognitively aware throughout their care, the contaminated supplies represented a breach of dignity as well as safety. They understood they needed help with toileting but had no control over whether that help followed basic hygiene principles.
Resident 52 faced more direct medical risk. With diabetes, a history of sepsis, and an open wound requiring regular dressing changes, contaminated wound care supplies could introduce bacteria directly into their bloodstream through the ankle injury.
The inspection found a pattern of staff shortcuts that put efficiency ahead of infection control. Gathering supplies in advance saved time. Skipping table cleaning saved time. Avoiding hand washing between glove changes saved time.
Each shortcut also increased the risk that residents would develop infections from the very care meant to keep them healthy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Continuing Healthcare of Cuyahoga Falls from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Continuing Healthcare of Cuyahoga Falls
- Browse all OH nursing home inspections