Federal inspectors observed the infection control violations during a December 23 complaint investigation at the 77-bed facility. Every medication pass they witnessed violated the facility's own hand hygiene policies.
The licensed practical nurse prepared insulin for one resident without washing hands before putting on gloves. After drawing medication into a syringe, the nurse used the contaminated gloves to handle the insulin bottle, place it back in storage, and lock the computer screen. Only after entering the resident's room and administering the injection did the nurse remove gloves and wash hands.
Minutes later, the same nurse dropped a pantoprazole tablet onto the medication cart surface. Without washing hands, the nurse put on a glove, picked up the medication from the cart, and placed it in a cup with other pills for a different resident.
A registered nurse committed similar violations while preparing medications for two other residents. The nurse used a pill cutter covered in white powder residue to cut a Guaifenesin tablet for chest congestion. The equipment was never cleaned.
The nurse poured the tablet directly onto the dirty pill cutter, put on gloves without washing hands, cut the medication, and placed half in a cup for the resident. After removing the glove, the nurse skipped hand hygiene entirely and returned the contaminated pill cutter to the medication cart for future use.
During another medication pass, the same registered nurse carried a Fluticasone-Salmeterol inhaler into a resident's room and placed it directly on the bedside table without any protective barrier. After the resident used the inhaler, the nurse took it back to the medication cart and stored it in its box without cleaning the device.
The facility's own policies require staff to follow infection control procedures during medication administration. A hand hygiene policy revised in August 2019 specifically mandates using alcohol-based hand rub or soap and water before and after handling medications, before applying gloves, and after removing gloves.
The Regional Nurse Consultant confirmed during an interview that staff should follow infection control measures at all times.
The violations occurred across multiple medication passes observed within a 40-minute window. Each incident involved different residents but the same contaminated equipment and surfaces that could spread infections throughout the facility.
The nurse who contaminated the insulin supplies used the same gloves to touch the medication bottle, storage drawer, and computer screen before entering a resident's room. The pill cutter covered in residue was returned to shared storage after cutting medication for one resident, ready to contaminate the next patient's pills.
Federal inspectors classified the violations as having minimal harm or potential for actual harm to residents. The facility reported no ongoing enforcement actions related to the findings.
The inspection occurred during a complaint investigation, though the specific nature of the complaint was not detailed in the federal report. Westwood Specialty Care serves 77 residents in Sioux City.
Infection control violations in nursing homes can lead to outbreaks of antibiotic-resistant bacteria, respiratory infections, and other communicable diseases that spread rapidly among vulnerable elderly populations. Proper hand hygiene and equipment cleaning are considered fundamental infection prevention measures.
The observed violations involved medications for diabetes, acid reflux, chest congestion, and lung inflammation. Each contaminated surface and piece of equipment could potentially transmit pathogens to subsequent residents receiving care.
The facility's infection control policy dates to April 2019, while the hand hygiene policy was last revised in August 2019. Both policies were in effect during the December inspection but were not followed during any of the four medication passes inspectors observed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westwood Specialty Care from 2025-12-31 including all violations, facility responses, and corrective action plans.