State inspectors documented the violations during a November 25 complaint investigation, finding that CNAs weren't properly sanitizing their hands or changing gloves at appropriate times during intimate care procedures.
The Assistant Director of Clinical Operations told inspectors at 2:03 PM that she expected nursing assistants to keep infection control "at the forefront of their mind" during catheter and incontinence care. She acknowledged that staff became nervous when state surveyors watched them work, but said she still expected proper protocols to be followed.
"It was important to ensure infection control practices were followed during incontinent or catheter care to prevent the risk of urinary tract infections," she told inspectors.
The facility's own policies appeared inadequate for the task. A review of the nursing home's Elimination and Perineal Care policy, effective since October 2021, showed it aimed "to provide cleanliness and comfort to the resident, to prevent infections and skin irritation." But the policy contained no specific guidance on infection control practices for catheter or incontinence care.
During a 2:26 PM interview, the Director of Clinical Operations was more direct about the consequences. She told inspectors that poor incontinence care "could have contributed to Resident #1 and Resident #2's recurrent UTIs."
She said staff were expected to sanitize their hands and change gloves at appropriate times during catheter and incontinence care "so the staff did not contaminate other body openings and decreased the risk of UTIs."
The director noted that staff had completed checkoffs, online training, and in-service education. She mentioned that several facilities would be providing a skills fair next month that would include incontinence care training.
The facility's administrator, interviewed at 3:01 PM, acknowledged he lacked clinical background and relied on administrative nursing staff to monitor infection control practices during intimate care procedures. He said he expected nursing staff to use "best practices" during catheter and incontinence care, calling proper protocols important "for infection control issues."
Despite the documented failures, recent competency evaluations suggested no problems. Records showed that both CNA A and CNA B had received passing marks on November 3 evaluations for incontinence care, with no negative comments noted on either assessment.
The Assistant Director of Clinical Operations told inspectors that nursing management provided in-service education and checkoffs for incontinence and catheter care "all the time." Yet the violations occurred despite this ongoing training.
The inspection findings highlight a gap between facility policies and actual practice. While administrators emphasized the importance of infection control during intimate care, the facility's written policy failed to address specific infection control practices for catheter or incontinence care.
State inspectors classified the violations as causing minimal harm or potential for actual harm, affecting few residents. But the acknowledgment by clinical leadership that improper care may have contributed to recurrent UTIs in at least two residents suggests the impact extended beyond policy violations to actual patient outcomes.
The November 25 complaint investigation revealed systemic issues with infection control training and oversight. Despite regular competency evaluations that showed staff meeting performance criteria, actual practice fell short of infection control standards when inspectors observed care being provided.
Urinary tract infections represent a significant health risk for nursing home residents, particularly those requiring catheter care or assistance with incontinence. Proper hand hygiene and glove changing protocols serve as primary barriers against bacterial transmission during intimate care procedures.
The facility's clinical directors understood these risks. Both emphasized during interviews that proper infection control practices were essential to prevent UTIs and avoid contaminating other body openings during care. Yet their staff failed to implement these practices consistently.
The inspection documented a facility where training existed on paper but failed in practice, where policies addressed comfort and cleanliness but omitted critical infection control specifics, and where recent competency evaluations missed problems that became apparent under state scrutiny.
For Resident #1 and Resident #2, the consequences of these systemic failures may have already manifested in the form of recurrent urinary tract infections that facility leadership acknowledged could have been prevented through proper care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care of Gilmer from 2025-11-25 including all violations, facility responses, and corrective action plans.