ELKO, NV - Highland Manor of Elko Rehabilitation LLC faced multiple federal citations during a July 2024 inspection that revealed serious infection control failures, including the dangerous placement of a vulnerable dialysis patient in the same room as a resident with an active MRSA infection.
Critical MRSA Exposure Puts Vulnerable Resident at Risk
The most serious violation involved Resident #40, who had tested positive for Methicillin-Resistant Staphylococcus Aureus (MRSA) in a wound culture on June 22, 2024. Despite federal guidelines requiring isolation protocols, the facility housed this resident with Resident #26, a dialysis patient with a port in their upper chest.
MRSA is a potentially life-threatening bacterial infection that resists many common antibiotics. It spreads through direct contact and contaminated surfaces, making proper isolation procedures critical in healthcare settings. Dialysis patients face heightened infection risks due to their compromised immune systems and the presence of medical devices that provide bacterial entry points.
Progress notes from June through July 2024 documented that Resident #40's wound dressings were frequently "saturated and coming off" or "falling off," creating additional contamination risks. Despite these concerning conditions, the facility allowed Resident #40 to eat meals in the shared dining room and did not implement proper isolation protocols.
Inadequate Staff Training and Protocol Understanding
Federal inspectors found concerning gaps in staff knowledge regarding infection control procedures. On July 16, 2024, a Certified Nursing Assistant entered the room of a resident on contact precautions without wearing the required gown and gloves. When questioned, a second CNA explained that PPE was only needed for "physical contact" with the infected resident, demonstrating inadequate understanding of CDC guidelines.
The facility's own Licensed Practical Nurse confirmed that staff received infection control training quarterly, yet multiple staff members displayed confusion about when personal protective equipment was required. According to CDC guidelines, healthcare personnel should wear gowns and gloves for all interactions that may involve contact with residents on contact precautions or potentially contaminated areas in their environment.
Leadership Knowledge Gaps Compromise Patient Safety
Perhaps most concerning, the facility's Director of Nursing (DON) demonstrated significant knowledge deficits during the inspection. On July 17, 2024, the DON admitted unfamiliarity with the facility's fall protocol and was unable to locate interdisciplinary team minutes. The DON also struggled to access and interpret resident medication administration records, including side effect monitoring documentation.
"The DON explained the DON's EMR training was informal and minimal," inspectors noted. This lack of training is particularly troubling given that the DON's job description requires accountability for directing all clinical services and overseeing nursing staff training programs.
Medication Safety Violations Create Additional Risks
Inspectors discovered expired medications in medication carts, including Fish Oil capsules that expired in January 2024 and Tramadol pain medication that expired in May 2024. A Registered Nurse acknowledged the monthly medication cart checks but explained that expired medications could cause residents to "get sick" if administered, and might not provide the prescribed therapeutic effects.
The facility's own pharmacy policy requires all expired medications to be returned to the pharmacy for proper disposal, yet these dangerous items remained accessible in medication carts where they could potentially be administered to residents.
Surveillance System Failures Mask Infection Spread
The facility failed to maintain adequate infection surveillance systems during July 2024. The Infection Prevention/Assistant Director of Nursing could not produce monthly infection tracking logs or infection mapping data for July, explaining they had been on vacation and had not yet started tracking for the month.
This surveillance gap is particularly dangerous because it prevents early identification of infection outbreaks and leaves administrators unable to determine whether infections are contained or spreading throughout the facility. The official noted they "would not know if an infection was currently contained or spreading throughout the facility" without current infection mapping.
Enhanced Barrier Precautions Missing for High-Risk Residents
Federal guidelines require Enhanced Barrier Precautions (EBP) for residents with chronic wounds or medical devices like catheters. However, inspectors found that residents requiring these precautions lacked proper signage and personal protective equipment carts at their room doors. Two residents who should have been on EBP protocols - one with an indwelling catheter and another receiving wound care - had no indication of special precautions needed.
Widespread Hand Hygiene Violations
Multiple staff members violated basic hand hygiene protocols that form the foundation of infection control. During dinner service, a Certified Nursing Assistant touched residents, served beverages, and handled food without performing hand hygiene between tasks over a 21-minute period. Similarly, an LPN administered medications to five residents without washing hands before or after each interaction.
Another CNA provided feeding assistance to two residents alternately without performing hand hygiene between residents, despite facility policy requiring hand washing "when between residents." These violations create direct pathways for infection transmission throughout the facility.
Administrative Response and Ongoing Concerns
The facility's Administrator confirmed during the inspection that the Assistant Director of Nursing held responsibility for infection control oversight, yet the surveillance failures and protocol violations suggest systemic problems with program implementation. The facility uses Point Click Care electronic documentation systems that include infection screening tools, but these systems proved ineffective when staff lacked proper training and oversight.
Federal regulations require nursing homes to maintain comprehensive infection prevention programs to protect vulnerable residents from healthcare-associated infections. The violations identified at Highland Manor represent serious departures from these standards that could endanger resident health and safety.
Medical Implications of Infection Control Failures
Healthcare-associated infections pose particular dangers in nursing home settings where residents often have compromised immune systems and multiple chronic conditions. MRSA infections can lead to bloodstream infections, pneumonia, and surgical site infections with mortality rates significantly higher than infections caused by antibiotic-sensitive bacteria.
Proper isolation protocols serve as critical barriers preventing infection transmission between residents and healthcare workers. When these protocols fail, facilities risk widespread outbreaks that can overwhelm medical resources and lead to serious resident harm.
The violations at Highland Manor demonstrate how interconnected infection control systems require consistent implementation across all levels of care. From basic hand hygiene to complex isolation procedures, each component plays a vital role in maintaining resident safety and preventing the spread of dangerous pathogens.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Manor of Elko from 2024-07-18 including all violations, facility responses, and corrective action plans.
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