The December 23 observation at Park View Care Center occurred during an active COVID-19 outbreak that had infected 10 of the facility's 62 residents. Housekeeping Manager #400 entered Resident #11's bathroom to clean her toilet wearing only an N95 mask, despite posted signage indicating the resident was in droplet precautions for COVID-19.
When confronted by inspectors 15 minutes later, the housekeeping manager confirmed she knew Resident #11 was in COVID-19 isolation and that staff should wear a gown, N95 mask, eye protection, and gloves while in the room. She admitted she "went into Resident #11's room to clean her toilet bowl and only wore the N95 mask she had on."
The same housekeeper then moved to a shared room housing Residents #12 and #13, both in COVID-19 precautions. She donned a gown and gloves before entering but kept the same N95 mask and failed to put on eye protection before walking past both residents to reach the bathroom.
Housekeeping Manager #400 told inspectors she had completed all room cleanings for the day, including rooms for five residents identified to be in COVID-19 precautions: Residents #11, #13, #21, #25, and #31. She cleaned all 24 rooms on her assignment without changing her N95 mask once.
A second housekeeper, #401, confirmed both staff members "do not change their N95 masks throughout the day." Both housekeepers told inspectors they "were unaware they were expected to discard their N95 mask before exiting a resident's room who was in COVID-19 droplet precautions."
The facility's own policy required staff to wear goggles or face shield, an N95 mask, a gown, and clean gloves before entering rooms in COVID-19 precautions. Federal guidance mandated that everyone "make sure their eyes, nose, and mouth are fully covered before room entry and make sure to remove face protection before room exit."
Infection Preventionist #301 confirmed the facility was experiencing a COVID-19 outbreak with 10 infected residents. None of the residents on the Memory Care Unit had been diagnosed with COVID-19. The infection preventionist acknowledged that N95 masks should be changed upon exiting COVID-19 rooms and that all staff should wear gown, gloves, N95 masks, and eye protection before entering rooms in COVID-19 precautions.
This outbreak represented the facility's second COVID-19 surge in recent months. The infection preventionist explained there had been just 29 days between the end of the previous outbreak in November 2025 and the current December outbreak.
The PPE violations were not isolated incidents. Resident Council meeting minutes from November 18 documented that "housekeeping staff were not using PPE in COVID-19 rooms before going into other rooms." The pattern had persisted for weeks before inspectors arrived.
During observations, inspectors noted the housekeeping manager wore a "distinct striped mask" that was not available in the PPE cart outside Resident #13's room, suggesting she had been wearing the same mask across multiple areas of the facility.
The inspection found that the improper PPE practices "had the potential to affect all residents in the facility" except the 10 residents already infected with COVID-19. With 52 residents still vulnerable to infection, the housekeepers' movement between infected and uninfected areas while wearing contaminated equipment created facility-wide exposure risks.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm" but noted it affected "some" residents in the 62-bed facility. The findings emerged during a complaint investigation completed on December 24.
The outbreak occurred despite the facility having experienced a previous COVID-19 surge just weeks earlier, suggesting ongoing challenges with infection control protocols. Staff interviews revealed a fundamental gap in understanding basic precautions, with housekeeping personnel unaware of requirements they were expected to follow during infectious disease outbreaks.
Park View Care Center's failure to ensure proper PPE use during an active outbreak highlighted systemic breakdowns in infection prevention training and oversight, particularly among environmental services staff who moved freely between isolation rooms and the general facility population.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park View Care Center from 2025-12-24 including all violations, facility responses, and corrective action plans.