The December 23 observation was one of multiple infection control violations federal inspectors documented at Westwood Specialty Care during a complaint investigation. Nurses repeatedly failed to wash their hands before handling medications and used contaminated equipment to prepare drugs for residents.
Staff A, the LPN, never washed her hands before putting on gloves to prepare insulin for a resident. She cleaned the insulin bottle with an alcohol swab while wearing the gloves, then touched the medication drawer and computer screen with the same contaminated gloves before entering the resident's room to administer the injection.
Minutes later, the same nurse prepared medications for another resident. When a pantoprazole pill dropped onto the top of the medication cart, she put on a glove without washing her hands first, picked up the dropped medication, and placed it in the cup with other pills.
A registered nurse used a pill cutter covered in white powder residue to split a chest congestion medication for a third resident. Staff B never cleaned the contaminated equipment before placing the tablet inside and cutting it. She put on gloves without washing her hands, cut the pill, then removed the gloves and failed to wash her hands afterward.
The same registered nurse placed an asthma inhaler directly on a resident's bedside table with no protective barrier underneath. After the resident used the inhaler, she carried it out of the room and returned it to the medication cart without wiping it down.
These violations occurred during a single morning medication pass at the 77-bed facility. Inspectors observed improper infection control practices with four different residents.
Westwood's own policies require staff to follow infection control procedures when administering medications. The facility's hand hygiene policy, revised in August 2019, specifically requires alcohol-based hand rub or soap and water before and after handling medications, before applying gloves, and after removing gloves.
The Regional Nurse Consultant told inspectors that staff should follow infection control measures at all times.
Federal regulations require nursing homes to maintain infection prevention and control programs to protect residents from healthcare-associated infections. The violations at Westwood created potential for cross-contamination between residents and medication supplies.
The inspection found nurses routinely skipped basic hand hygiene steps that prevent the spread of bacteria and viruses in healthcare settings. Using contaminated gloves to touch computer screens and medication storage areas created additional opportunities for infection transmission.
Dropping medications onto potentially contaminated surfaces and then administering them to residents violated fundamental medication safety protocols. The white powder residue on the pill cutter suggested the equipment had been used previously without proper cleaning between residents.
Placing medical equipment like inhalers directly on bedside tables without protective barriers exposed the devices to environmental contamination. Returning the inhaler to storage without cleaning it risked contaminating other medication supplies.
The violations occurred despite the facility having written policies addressing these exact scenarios. Staff either ignored the requirements or lacked adequate training on infection control procedures during medication administration.
Federal inspectors classified the violations as having minimal harm or potential for actual harm to residents. However, improper infection control practices in nursing homes can lead to serious outbreaks of respiratory infections, gastrointestinal illnesses, and antibiotic-resistant bacteria.
The December inspection was conducted in response to a complaint about conditions at the facility. Inspectors focused their review on infection prevention and control practices during routine nursing care activities.
Westwood Specialty Care must submit a plan of correction detailing how it will ensure staff follow proper hand hygiene and infection control procedures during medication administration. The facility faces potential enforcement action if it fails to address the violations adequately.
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.