The December incident at Westwood Specialty Care illustrates systematic infection control failures that federal inspectors documented during a complaint investigation. Staff repeatedly skipped hand washing, used contaminated equipment, and touched multiple surfaces with soiled gloves during medication passes for four residents.
The 77-bed facility's nurses violated their own policies requiring hand hygiene before and after handling medications and before applying gloves.
On December 23, inspectors watched Staff A, a licensed practical nurse, prepare insulin for a resident without washing hands before putting on gloves. The nurse cleaned an insulin bottle with an alcohol swab, drew up the medication, then used the same gloved hands to lock the computer screen before entering the resident's room.
After administering the insulin and removing gloves, the nurse finally performed hand hygiene.
Eleven minutes later, the same nurse was preparing medications for another resident when a pantoprazole tablet fell onto the medication cart surface. Without washing hands, Staff A put on a glove, picked up the dropped pill, and placed it in the medication cup with other pills. The nurse removed the glove, washed hands, and gave the medications to the resident.
A registered nurse identified as Staff B created additional contamination risks while preparing chest congestion medication for a different resident. The nurse retrieved a pill cutter from the medication cart that had white powder residue on both the top and bottom surfaces.
Staff B did not clean the contaminated equipment. Instead, the nurse poured a tablet directly from the bottle onto the dirty pill cutter, then put on gloves without washing hands first. Using gloved hands, Staff B positioned the tablet and cut it in half, placing one piece in a medication cup and disposing of the other half in a sharps container.
The nurse removed the glove without performing hand hygiene afterward, returned the contaminated pill cutter to the medication cart, and continued preparing medications for the same resident.
During another medication pass, Staff B brought an inhaler for lung inflammation directly into a resident's room and placed it on the bedside table without any protective barrier. After administering the medications and inhaler, the nurse left the room carrying the inhaler and returned it to its box in the medication cart without wiping it down.
The facility's own policies, revised as recently as August 2019, explicitly require staff to use alcohol-based hand rub or soap and water before and after handling medications, before applying gloves, and after removing gloves. An April 2019 medication administration policy states that staff must follow established infection control procedures when giving medications.
When inspectors interviewed the Regional Nurse Consultant on December 23, the administrator acknowledged that staff should follow infection control measures at all times.
The violations occurred across multiple medication passes and involved both licensed practical nurses and registered nurses, suggesting the problems were not isolated incidents but part of a pattern of poor infection control practices.
Cross-contamination from unwashed hands and contaminated equipment can spread bacteria, viruses, and other pathogens between residents, particularly dangerous in nursing home settings where many residents have compromised immune systems or chronic health conditions.
The inspection was conducted in response to a complaint, though the specific nature of the complaint was not detailed in the federal report. Inspectors classified the violations as causing minimal harm or potential for actual harm to residents.
Federal regulators found the facility failed to provide and implement an adequate infection prevention and control program, affecting some residents at the 77-bed facility.
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.