SAINT PAUL, MN - Federal inspectors documented significant infection control failures at Good Samaritan Society - Maplewood during a COVID-19 outbreak that infected five residents, finding staff repeatedly violated protective protocols and failed to implement required testing measures.
COVID-19 Outbreak Mismanagement
During an August 2024 inspection, surveyors identified a COVID-19 outbreak affecting five residents that the facility failed to manage according to Centers for Disease Control and Prevention guidelines. The outbreak began when a family member who tested positive for COVID-19 visited a resident without wearing a mask and without informing staff of their infection status.
Between the dates documented in the report, five residents on Team 3 tested positive for COVID-19. However, the facility failed to implement the broad-based testing approach recommended by the CDC when an outbreak cannot be contained through contact tracing alone.
According to CDC guidance for nursing homes, when contact tracing fails to halt transmission, facilities should implement broad-based testing of affected units every 3 to 7 days until no new cases appear for 14 days. The facility's infection preventionist acknowledged completing contact tracing but did not promptly test the four other residents housed on the same team as the infected residents.
These four residents were only tested after federal surveyors arrived at the facility, despite being in close proximity to multiple COVID-positive residents for days. The Director of Nursing admitted during the interview that testing was not completed promptly enough.
Widespread Personal Protective Equipment Violations
Inspectors observed multiple instances of staff failing to wear appropriate protective equipment when caring for COVID-positive residents and those requiring enhanced barrier precautions. The violations placed both staff members and other residents at risk of infection transmission.
One nursing assistant entered the rooms of two COVID-positive residents wearing two surgical masks instead of a properly fitted N95 respirator. When questioned, the staff member stated, "I can't breathe with an N95 mask on so I wear 2 surgical masks instead." The assistant also failed to wear required eye protection, claiming the facility was sometimes short on that equipment.
Surgical masks do not provide the same level of protection as N95 respirators against airborne particles. N95 respirators are designed to filter at least 95 percent of airborne particles and create a seal around the nose and mouth. Wearing two surgical masks does not replicate this protection and leaves staff vulnerable to infection.
Multiple staff members were observed wearing N95 masks incorrectly with surgical masks underneath, compromising the fit and effectiveness of the respirator. Staff also used personal eyeglasses instead of proper face shields or goggles, which do not provide adequate protection from respiratory droplets.
One registered nurse entered a COVID-positive resident's room without eye protection, stating they were "just giving the resident his pills" and didn't need full protective equipment. Another nursing assistant delivered a meal tray without eye protection, claiming PPE wasn't necessary since they weren't performing direct care.
The facility's own policies and CDC guidelines require full personal protective equipment—including N95 respirator, face shield, gown, and gloves—for anyone entering the room of a COVID-positive resident, regardless of the duration or type of contact.
Hand Hygiene and Glove Change Failures
Inspectors documented multiple failures in basic infection control practices related to hand hygiene and glove use. Proper hand hygiene between tasks is a fundamental measure for preventing the spread of pathogens in healthcare settings.
During one observed care episode, a nursing assistant provided toileting assistance to a resident, handling soiled incontinence products and cleaning the resident, but failed to remove gloves and perform hand hygiene before touching clean supplies. The assistant removed the soiled product, left the bathroom to retrieve a clean product, returned, and completed care—all while wearing the same contaminated gloves.
When bacteria and other microorganisms on contaminated gloves contact clean surfaces or supplies, those items become vehicles for transmitting infection to other residents. Hand hygiene between glove changes eliminates this transmission pathway.
In another incident involving a resident requiring enhanced barrier precautions, nursing assistants changed gloves multiple times during bathing and dressing without performing hand hygiene between glove changes. Staff removed gloves contaminated with wound drainage and body fluids, then immediately donned new gloves without cleaning their hands.
The same care episode revealed staff failing to wear required gowns despite clear signage outside the resident's room indicating enhanced barrier precautions. Multiple staff members entered to assist with transferring, bathing, and wound care wearing only gloves, allowing their scrubs to contact the resident's bed linens soiled with stool and wound drainage.
Enhanced Barrier Precautions Not Followed
The facility placed residents with wounds, catheters, and other medical devices on enhanced barrier precautions, but staff repeatedly failed to follow the required protocols. EBP requires gowns and gloves for high-contact care activities including dressing, bathing, transferring, providing hygiene, changing linens, and repositioning.
During an observed shower, two nursing assistants transferred a resident with moisture-associated skin damage and a draining wound from bed to shower chair without wearing gowns. One assistant's scrub top touched the resident's bed, which had visible stool on the draw sheet. The center of a bandage covering a wound on the resident's buttocks showed saturation with drainage.
Throughout the bathing process, one assistant repeatedly removed and reapplied gloves without hand hygiene. The assistant removed soiled linens, applied clean linens, dressed the resident, tidied the room, and transported dirty laundry—all tasks completed with multiple glove changes but no hand washing.
The failure to wear gowns during high-contact care allows clothing to become contaminated with wound drainage, body fluids, and fecal matter. Staff then carry these pathogens on their clothing as they move throughout the facility, potentially transmitting infections to other residents.
Pressure Ulcer Monitoring Gaps
In addition to infection control failures, inspectors found the facility failed to complete required weekly skin assessments for two residents at risk for pressure ulcers. Weekly skin assessments allow early detection of skin breakdown so interventions can prevent progression to more serious wounds.
The facility's own quality assurance data showed they were exceeding state and national averages for high-risk pressure ulcers, with a rate of 9.1 percent compared to the state average of 7.3 percent and national norm of 9.0 percent. Quality improvement meeting minutes documented ongoing issues with residents not complying with repositioning and offloading measures, though the minutes did not address the missing weekly assessments.
Pressure ulcers develop when sustained pressure on the skin reduces blood flow to the tissue. Without adequate blood flow, skin and underlying tissue become damaged. Regular repositioning distributes pressure across different areas of the body, while skin assessments detect early warning signs like redness that indicate areas at risk.
The Director of Nursing stated the facility had contracted with a wound care company for weekly visits and addressed pressure ulcers in interdisciplinary team meetings, emphasizing the importance of documentation. However, the primary issue remained getting nurses to complete skin assessments rather than putting them aside.
Systemic Infection Control Concerns
The multiple, repeated failures documented during the inspection point to systemic weaknesses in the facility's infection prevention program. Staff demonstrated consistent lack of adherence to basic infection control principles across different shifts and roles.
The infection preventionist worked only three days per week, potentially limiting oversight and real-time intervention during the outbreak. While the facility had policies requiring appropriate PPE use and hand hygiene, staff clearly did not consistently follow these protocols.
The Director of Nursing acknowledged staff were supposed to wear N95 masks fitted to their face without surgical masks underneath, use proper eye protection rather than personal glasses, and perform hand hygiene before and after glove use. However, observations revealed widespread non-compliance with these expectations.
When staff fail to follow basic infection control measures, the risk of disease transmission increases substantially. In a nursing home setting where residents often have compromised immune systems and multiple chronic conditions, infections can lead to serious complications, hospitalizations, and death.
Regulatory Context
Federal regulations require nursing homes to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The program must include systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases.
Facilities must also prevent the development and transmission of communicable diseases and infections according to nationally recognized infection prevention and control guidelines. The failures documented at Good Samaritan Society - Maplewood represent violations of these fundamental requirements.
The inspection resulted in citations for failing to implement proper infection prevention and control measures and failing to ensure appropriate assessment and monitoring of residents at risk for pressure ulcers. The facility was required to submit a plan of correction detailing how they would address the identified deficiencies.
For family members and prospective residents, these findings raise important questions about the facility's ability to protect residents from preventable infections and provide appropriate monitoring for common complications of nursing home care. The full inspection report provides additional details about the scope and nature of the violations documented by federal surveyors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Maplewood from 2024-08-22 including all violations, facility responses, and corrective action plans.
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