The aide also threw the soiled linens directly onto the floor of the resident's room.
Federal inspectors documented the infection control failures at Country Club Retirement Center IV during a November 24 complaint investigation. The 46-bed facility received citations for violating basic hygiene protocols during intimate care.
The resident, identified as #5 in inspection records, had been admitted just over a month earlier on October 21 with multiple serious conditions. Medical records showed diagnoses including chest pain, heart disease, high blood pressure, cerebrovascular disease, previous heart attack, paranoid schizophrenia, and a displaced hip fracture.
A care plan from the admission date indicated the resident needed staff assistance with all activities of daily living due to decreased mobility. Staff were supposed to help with incontinence care, toileting, bed mobility, dressing, and laundry.
Inspectors observed the problematic care on November 24 at 10:10 a.m. Certified nurse aide #115 was providing incontinence care following the resident's bowel movement.
After cleaning the resident's perineal area, the aide failed to follow basic infection control steps. She did not wash her hands. She did not change her contaminated gloves. Instead, she proceeded directly to apply barrier cream and put on a new incontinence brief while wearing the same gloves she had used during cleanup.
The violations continued when the aide changed the bed linens. Rather than placing the contaminated materials in a bag or designated container, she put the soiled linens directly on the floor of the resident's room.
Following the care, inspectors interviewed the aide. She confirmed she had not washed her hands, changed gloves, or used a linen bag during the entire care process.
At 10:43 a.m., inspectors spoke with the facility's Director of Nursing. She acknowledged that hands should be washed between performing perineal care and putting on new gloves. She also confirmed that soiled linens should be placed immediately into a bag or linen barrel, not on the floor.
The facility's own written policy supported the director's statements. A document titled "Perineal Care" and dated June 4, 2021, stated the procedure's purpose was "to prevent infection and odors and promote comfort."
The policy required staff to wear gloves during perineal care and to place soiled washcloths, towels and linens on an "impermeable barrier" during the cleaning process. It specified that staff should remove gloves and wash hands following care.
However, the policy contained a significant gap. It provided no guidance about hand hygiene or glove changing when applying incontinence briefs or barrier cream following perineal care.
This omission may have contributed to the aide's failure to recognize the need for clean hands and gloves when touching the resident's skin and applying products after cleanup.
The inspection was conducted in response to a complaint filed under number 2649219. Federal regulators classified the violations as causing "minimal harm or potential for actual harm."
The failures represent basic infection control breakdowns that could expose vulnerable nursing home residents to preventable infections. Proper hand hygiene and contaminated material handling are fundamental safeguards in healthcare settings, particularly during intimate care procedures.
The resident affected by the substandard care was already dealing with multiple serious medical conditions, including heart disease and a recent hip fracture. Such residents are typically at higher risk for infections and complications from poor hygiene practices.
Country Club Retirement Center IV must now address both the immediate violations and the policy gap that may have enabled them. The facility's infection prevention and control program failed to ensure staff followed basic protocols during one of the most infection-sensitive care procedures in nursing homes.
The case illustrates how seemingly simple care tasks can become sources of serious health risks when staff skip fundamental safety steps. For residents who depend entirely on staff for intimate care, proper infection control isn't just policy compliance – it's a basic protection of their health and dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Club Retirement Ctr IV from 2025-11-25 including all violations, facility responses, and corrective action plans.
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