SEO_DESCRIPTION: Island Health and Rehabilitation Center in Merritt Island faces infection control violations including improper PPE storage and unsanitary equipment practices.
OG_TITLE: Merritt Island Nursing Home Cited for Multiple Infection Control Violations
OG_DESCRIPTION: Federal inspectors found Island Health and Rehabilitation Center failed to properly implement infection prevention protocols, putting residents at risk through inadequate PPE access and unsanitary storage practices affecting 30 residents.
FB_POST: Merritt Island nursing home cited for infection control failures - improper PPE storage, unsanitary equipment practices found
ARTICLE:
MERRITT ISLAND, FL - Federal inspectors cited Island Health and Rehabilitation Center for significant infection control violations that compromised resident safety protocols and increased disease transmission risks.
Widespread Enhanced Barrier Precaution Failures
The January 17, 2025 inspection revealed systematic failures in the facility's Enhanced Barrier Precaution (EBP) program, which is designed to prevent the spread of multidrug-resistant organisms among vulnerable nursing home residents. Thirty residents were supposed to be on EBP protocols, but inspectors found widespread non-compliance with safety requirements.
The most serious violation involved incorrect signage and missing personal protective equipment for residents requiring enhanced precautions. Resident #5, who was on EBP due to wounds, had contact isolation signage posted instead of the required EBP signage. More critically, the appropriate PPE was not readily available at the resident's door as required by facility policy.
A Certified Nursing Assistant providing one-on-one observation to the resident stated that "gloves were in the room, but no other PPE was in place." This represents a significant infection control breach, as wound care requires proper gowns and gloves to prevent bacterial transmission between residents and staff.
PPE Access Problems Create Safety Risks
The facility's Infection Preventionist, who also served as Assistant Director of Nursing, acknowledged multiple protocol violations during the inspection. She confirmed that 30 residents were currently on EBP but was unable to verify if proper signage was posted for them.
Licensed Practical Nurse E described the operational challenges created by inadequate PPE placement: "If she had to do catheter care she would need PPE and would have to go to the CNAs supply room at the nurses' station instead of having it readily available at the resident's room."
This system creates dangerous delays in infection control protocols. Medical research shows that immediate access to appropriate PPE is essential for preventing healthcare-associated infections, particularly in facilities caring for immunocompromised elderly residents.
Policy Violations and Equipment Storage Issues
The facility's own Enhanced Barrier Precautions policy, effective April 1, 2024, clearly states requirements to "Make gown and gloves available inside of the resident's room" and "PPE to be kept inside resident room and easily accessible for use." Inspectors found these requirements were not being met.
The Infection Preventionist explained that prior to January 1, 2025, PPE caddies were placed outside resident rooms in hallways but were removed "due to pilferage." This created a system where staff had to retrieve PPE from a central supply room, significantly delaying proper infection control procedures.
CNA B confirmed the operational problems, stating that retrieving PPE from the central supply room "was a lengthy process" when providing care for EBP residents.
Unsanitary Equipment Storage Practices
Inspectors also documented improper storage of resident care equipment that violated basic infection control standards. On multiple occasions, they observed two basins on the bathroom floor in room A-17 that were not labeled with individual resident names and were not stored in plastic bags.
Registered Nurse F acknowledged the violations, stating that "in a perfect world resident's equipment/basin should be labeled, placed in a plastic bag, and stored in the resident's closet, not stored on the floor." The Infection Preventionist confirmed that proper infection control practices require equipment to be "labeled and placed in the individual residents' closet/drawer to prevent cross contamination."
Medical Significance of Violations
Enhanced Barrier Precautions are implemented specifically for residents with gastrostomy tubes, indwelling catheters, and wounds - all of which create increased infection risks. These medical devices provide direct pathways for bacteria to enter the body, making proper PPE use critical for preventing life-threatening infections.
Improper equipment storage compounds these risks by creating opportunities for cross-contamination between residents. When basins and other care items are stored on bathroom floors without proper labeling or protective covering, they can harbor harmful bacteria that spread between patients.
Healthcare-associated infections in nursing homes can lead to sepsis, prolonged hospitalizations, and increased mortality rates among elderly residents who already have compromised immune systems.
Administrative Response and Systemic Issues
The facility's Administrator acknowledged significant problems during the inspection, stating there was "obvious system breakdown which needed to be addressed" regarding the repeat citations. He confirmed that Quality Assurance and Performance Improvement (QAPI) committees met monthly to review data and develop improvement plans.
On January 15, 2025, one day before the inspection concluded, the facility held a QAPI meeting to implement new procedures placing EBP signs above residents' beds and maintaining PPE supplies at the nurses' station. However, this reactive approach highlighted the systematic nature of the compliance failures.
Regulatory Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs that protect residents from healthcare-associated infections. These standards mandate readily available PPE, proper signage for transmission-based precautions, and sanitary storage of resident care equipment.
The violations at Island Health demonstrate failures across multiple aspects of infection control protocols that are fundamental to resident safety in long-term care facilities. Proper implementation of these standards is particularly critical given the vulnerability of nursing home populations to infectious diseases.
The facility must develop and implement corrective action plans to address these deficiencies and demonstrate sustained compliance with federal infection control requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Island Health and Rehabilitation Center from 2025-01-17 including all violations, facility responses, and corrective action plans.
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