The December 1 inspection at Aurora Manor Special Care Center documented the infection control violation during care for Resident #42, who requires complete assistance with toileting and is always incontinent of bowel and bladder.
Federal inspectors observed Certified Nurse Aid #128 at 1:10 p.m. providing incontinence care. The aide placed supplies directly onto the bedside table without cleaning the surface or using a protective barrier.
During the care, CNA #128 removed her soiled gloves and walked to the resident's bathroom to get additional supplies. She then immediately put on a new pair of gloves without performing hand hygiene before continuing the incontinence care.
The aide confirmed these actions when interviewed at 1:22 p.m. the same day.
Resident #42 was admitted to the facility with multiple conditions including cerebral palsy, high blood pressure, Alzheimer's disease, and a history of falls. A Minimum Data Set assessment revealed the resident has cognitive impairment and depends entirely on staff for toileting assistance.
Aurora Manor's own Hand Hygiene Policy, dated February 28, 2025, requires hand hygiene immediately after glove removal.
The violation emerged during a complaint investigation completed December 1. Inspectors noted it as an "incidental finding" discovered while investigating the original complaint.
Federal regulators classified the infection control failure as causing minimal harm or potential for actual harm. The violation affected one of four residents reviewed for incontinence care practices.
Hand hygiene represents a basic infection prevention measure in healthcare settings. The Centers for Disease Control and Prevention identifies proper hand washing as one of the most effective ways to prevent the spread of germs and infections in healthcare facilities.
For residents like #42 who require extensive personal care and have compromised immune systems due to multiple medical conditions, proper infection control becomes particularly critical. Residents with cognitive impairment cannot advocate for themselves or report when staff skip safety protocols.
The inspection found that Aurora Manor failed to ensure infection control standards were implemented during incontinence care, despite having written policies requiring proper hand hygiene procedures.
CNA #128's actions violated the facility's own infection prevention protocols. By skipping hand washing between removing contaminated gloves and donning clean ones, the aide potentially transferred bacteria and other pathogens from her hands to the new gloves, then to the resident during continued care.
The bedside table contamination added another infection risk. Placing supplies directly on an uncleaned surface without a barrier could expose clean materials to germs from previous use.
Aurora Manor now faces federal scrutiny over its infection prevention and control program implementation. The facility must demonstrate how it will ensure staff follow established hand hygiene protocols during resident care.
The violation occurred despite clear written policies. Aurora Manor's Hand Hygiene Policy explicitly states the requirement for immediate hand washing after glove removal, yet staff failed to follow this basic safety measure during observed care.
Resident #42 remains dependent on Aurora Manor staff for all toileting needs. The resident's multiple diagnoses, including Alzheimer's disease and cerebral palsy, require consistent, safe care practices to prevent additional health complications from preventable infections.
The December inspection represents the latest federal review of Aurora Manor's care practices. Inspectors will continue monitoring the facility's compliance with infection prevention requirements as part of ongoing oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aurora Manor Special Care Cent from 2025-12-01 including all violations, facility responses, and corrective action plans.