The December 23 inspection at Claymont Health and Rehabilitation revealed a cascade of infection control failures during what should have been routine incontinence care for a resident with dementia and major depression.
Federal inspectors observed the violations at 5:24 a.m. when Certified Nursing Assistant #111 entered the room of Resident #17. The resident's shirt, bedsheet from his waist to his head, and three-fourths of his pillowcase were wet with urine. A faint smell of urine filled the room.
The assistant washed her hands and put on gloves before removing the resident's incontinence brief, which was only slightly moist. She discovered the resident had experienced a moderate-sized bowel movement.
What happened next violated multiple infection control protocols.
After cleaning the resident's perineum and buttocks, the assistant kept her soiled gloves on. She walked to the closet and retrieved clean pants and a shirt with the contaminated gloves. She placed a fresh incontinence brief on the resident and pulled his pants up to his knees.
The assistant then helped the resident sit up and put on his socks and shoes. She placed a clean shirt over his unwashed torso, leaving his back and head wet with urine.
Still wearing the same gloves contaminated with fecal matter, she grabbed the resident's walker and helped him stand and transfer to his wheelchair.
Then she asked if he had razor burn and touched his right cheek with the soiled gloves.
Only after completing all these tasks did the assistant remove the dirty linens, take off her gloves, and wash her hands.
The resident affected by these violations had been admitted to the facility on January 13. His medical record showed diagnoses including dementia, major depression, chronic obstructive pulmonary disease, and difficulty swallowing. His quarterly assessment indicated he was frequently incontinent of bladder and occasionally incontinent of bowel, requiring partial to moderate assistance with toileting.
When questioned at 5:54 a.m., the nursing assistant confirmed she had not completely cleaned the resident before dressing him and acknowledged she failed to maintain proper infection control during the observed care.
The facility's Director of Nursing, interviewed later that morning, stated it would have been her expectation for the assistant to cleanse the resident's upper body after an incontinence episode before getting him dressed. She confirmed the assistant did not follow proper infection control practices.
The facility's own policy, titled "Skin: Incontinence Care Protocol" and dated September 2017, outlined clear procedures for incontinence care. The policy stated care should maintain skin integrity, prevent skin breakdown, control odor, and provide comfort and self-esteem for residents.
The protocol required proper hand hygiene and wearing gloves when providing care. Staff were to cleanse with perineal wash or mild cleanser, pat dry while avoiding friction, apply protective ointment as directed, and change linens and clothing as needed.
None of these steps were properly followed.
The inspection was conducted as part of a complaint investigation numbered 2619625. Federal inspectors reviewed four residents for incontinence care, finding violations affecting one of the four examined.
Claymont Health and Rehabilitation operates with a census of 52 residents. The facility received a citation for failing to provide and implement an adequate infection prevention and control program, with inspectors determining the violation caused minimal harm or potential for actual harm.
The case illustrates how basic care failures can compound. What began as routine incontinence care became a series of infection control violations that left a vulnerable resident with dementia partially unwashed and exposed to contamination from his own waste through cross-contamination on his caregiver's gloves.
The resident spent his morning sitting in his wheelchair with a urine-soaked back and head that had never been cleaned, wearing a fresh shirt over skin that remained wet from his incontinence episode.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Claymont Health and Rehabilitation from 2025-12-23 including all violations, facility responses, and corrective action plans.
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