The December 23 observation at Westwood Specialty Care revealed systematic infection control failures during medication administration that affected multiple residents at the 77-bed facility.
Federal inspectors documented four separate incidents where licensed nurses violated basic hand hygiene protocols while preparing and administering medications to residents.
Staff A, a licensed practical nurse, drew up insulin while wearing gloves, then used the same contaminated gloves to touch the computer screen before entering the resident's room. The nurse had failed to perform hand hygiene before putting on the gloves initially.
Minutes later, the same nurse prepared medications for another resident. When a pantoprazole tablet dropped onto the medication cart surface, Staff A put on a glove without washing hands first, picked up the medication from the cart, and placed it into the medication cup with other pills.
The contamination extended to shared equipment. Staff B, a registered nurse, used a pill cutter covered with white powder residue to cut a Guaifenesin tablet for a resident. The nurse did not clean the pill cutter before use, applied gloves without hand hygiene, cut the tablet, then returned the contaminated cutter to the medication cart without cleaning it.
After cutting the medication, Staff B disposed of half the tablet in the sharps container, removed the glove, and proceeded to finish preparing medications without performing hand hygiene.
The infection control violations continued with respiratory medications. Staff B brought a resident's Fluticasone-Salmeterol inhaler into the room and placed it directly on the bedside table without any protective barrier. After administering the inhaler, the nurse returned it to the medication cart without wiping it down, despite the device having contacted the potentially contaminated surface.
The facility's own policies required strict adherence to infection control procedures. The medication administration policy, revised in April 2019, specifically stated that staff must follow established facility infection control procedures when administering medications.
The hand hygiene policy, updated in August 2019, mandated alcohol-based hand rub or soap and water before and after handling medications, before applying gloves, and after removing gloves.
When interviewed on December 23, the Regional Nurse Consultant confirmed that staff should follow infection control measures at all times.
The violations occurred during routine medication passes observed over a 40-minute period on December 23. Each incident involved different residents, demonstrating that the infection control failures were not isolated to a single nurse or situation.
The contaminated pill cutter presented particular concern, as it would be used for multiple residents requiring split medications. The white powder residue suggested previous use without proper cleaning between patients.
Similarly, the practice of using the same gloves to touch computer equipment, medication bottles, and then administer medications created multiple opportunities for cross-contamination between residents.
The inhaler placement on an unprotected bedside table surface, followed by return to the medication storage area without decontamination, created another pathway for infection transmission.
Federal inspectors classified the violations as having minimal harm or potential for actual harm to residents. However, the systematic nature of the failures across multiple staff members and medication passes indicated broader problems with infection control training and oversight.
The facility reported no specific enforcement actions in the inspection report, though the violations occurred during a complaint-based inspection conducted on December 31, 2024.
The observations revealed that despite having detailed written policies addressing both medication administration and hand hygiene protocols, staff were not implementing these basic infection control measures during actual patient care.
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.