Federal inspectors documented repeated infection control failures during medication administration at Westwood Specialty Care, finding nurses skipped hand washing and contaminated equipment while caring for residents on December 23.
The violations affected four residents during a single morning medication pass at the 77-bed facility.
Staff A, a licensed practical nurse, failed to wash hands before putting on gloves at 9:01 a.m. while preparing insulin for a resident. After drawing the medication into a syringe, the nurse used the contaminated gloves to touch the computer screen to lock it, then entered the resident's room still wearing the same gloves to give the injection.
Ten minutes later, the same nurse prepared medications for another resident. When a pantoprazole tablet fell onto the medication cart surface, Staff A put on a glove without washing hands, picked up the dropped pill, and placed it in the medication cup with other pills.
A registered nurse violated protocols while preparing chest congestion medication for a third resident at 9:27 a.m. Staff B used a pill cutter covered with white powder residue without cleaning it first. The nurse poured the tablet directly onto the contaminated cutter, put on gloves without hand hygiene, cut the tablet in half, and placed one piece in the medication cup.
After removing the gloves, Staff B failed to wash hands again and returned the dirty pill cutter to the medication cart for the next medication preparation.
The most concerning incident occurred at 9:40 a.m. when Staff B brought 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 placed it in its storage box without wiping it down.
The facility's own policies required staff to follow infection control procedures during medication administration. A policy revised in August 2019 specifically mandated hand washing or alcohol-based hand rub before and after handling medications, before applying gloves, and after removing gloves.
"Staff should be following infection control measures at all times," the Regional Nurse Consultant told inspectors during an interview.
The violations create multiple pathways for infection transmission. Contaminated gloves transfer bacteria and viruses between surfaces, residents, and equipment. Dirty pill cutters can cross-contaminate medications between different patients. Placing inhalers directly on bedside tables exposes the devices to whatever bacteria or viruses may be present on those surfaces.
Each breach compounds the risk. When Staff A touched the computer screen with contaminated gloves, any pathogens on those gloves remained on the keyboard and screen for the next person to encounter. When Staff B returned the uncleaned pill cutter to the medication cart, the white powder residue remained available to contaminate the next resident's medication.
The inspection found these violations during a single morning observation period, suggesting the practices were routine rather than isolated incidents. Four different residents received medications from nurses who failed to follow basic infection control protocols their own facility required.
Hand hygiene represents the most fundamental infection prevention measure in healthcare settings. The Centers for Disease Control and Prevention identifies proper hand washing as the single most effective way to prevent the spread of infections in healthcare facilities.
At Westwood Specialty Care, nurses repeatedly skipped this basic protection while handling medications that go directly into residents' bodies. The contaminated equipment and surfaces they left behind remained ready to spread whatever pathogens the next shift might encounter.
The facility reported no immediate enforcement action, but federal regulators classified the violations as having potential for actual harm to residents.
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.