The violation occurred at 5:00 a.m. on November 20 while RN B was replacing feeding tube supplies for a resident who receives nutrition through a gastrostomy tube. Physician orders required the facility to change all feeding tube equipment and water bags every Wednesday night shift.
Inspectors watched as the nurse put on gloves, gown and mask, then removed the resident's used tubing and water bag. She threw the contaminated supplies in the trash, then opened the bathroom door, removed the cap from a new water bag, and filled it with water.
The nurse returned to the resident's bedside and connected new tubing to the gastrostomy tube. She hung the new water bag and a fresh bottle of formula. Then she removed her gloves and left the room.
She never put on fresh gloves. She never washed her hands or used sanitizer between handling the dirty supplies and the clean ones.
The Director of Nursing, who also serves as the facility's infection control preventionist, told inspectors that staff must change gloves "from dirty to clean" and wash their hands or use sanitizer when performing care. She said she had conducted an in-service training on this exact topic within the past three weeks.
"The importance of changing gloves and washing hands during care," she called it.
During that recent training, the DON said some certified nursing assistants required extra time "to make sure they understood." But the staff didn't ask questions and "appeared to understand and indicated they knew everything."
The consequences of ignoring these protocols are clear, the DON acknowledged. When staff don't change gloves and clean their hands properly, "they could spread germs to themselves and the residents."
The facility's own infection control policy, updated in December 2024, requires employees to wash hands for at least 20 seconds with soap and water in specific situations: after direct contact with residents, after removing gloves, and after handling items potentially contaminated with blood, body fluids, or secretions.
The policy covers "high-contact resident care activities" including dressing, grooming, transferring, providing hygiene, changing linens, and changing briefs. It requires staff to keep supplies "available for usage, but in a clean supply area."
Feeding tube care involves direct contact with equipment that delivers nutrition directly into a resident's stomach through a surgically created opening. The tubes and water bags collect residue from formula and stomach contents during use.
RN B's actions violated basic infection control principles by creating a pathway for bacteria and other pathogens to move from contaminated waste to clean medical equipment. Her gloves picked up germs from the used tubing and water bag, then transferred those contaminants to the new supplies she touched immediately afterward.
The violation occurred despite recent facility-wide training specifically addressing glove changes and hand hygiene during resident care. The DON's admission that some staff needed extra instruction suggests the facility was already aware of compliance problems with infection control protocols.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. But the failure represents a fundamental breakdown in infection prevention that could have exposed the resident to dangerous bacteria or other pathogens through contaminated feeding equipment.
The resident requiring tube feeding likely has compromised health that makes them particularly vulnerable to infections. Contaminated feeding supplies could introduce harmful bacteria directly into their digestive system, potentially causing serious illness.
The inspection found that despite policy requirements and recent training, nursing staff continued to ignore basic infection control measures that protect both residents and healthcare workers from the spread of disease.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carrollton Health and Rehabilitation Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
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