The incident at Polaris Extended Care was captured in photographs dated April 25, 2023, showing Certified Nursing Assistant #3's ungloved hand on Resident #48's pressure ulcer. The resident had been admitted with multiple strokes resulting in severe speech problems, difficulty swallowing, partial paralysis on the right side, and failure to thrive.
Federal inspectors found the facility failed to ensure proper infection control practices during wound care for two residents during their July inspection. The violations created potential risk for infection in wounds and decreased healing.
Resident #48's care plan specifically required enhanced barrier precautions, instructing staff to use gowns and gloves during high-contact activities. The resident suffered from diabetes and multiple cerebrovascular accidents that left him with severe expressive aphasia and right-sided weakness.
When presented with the photograph during interviews, facility staff acknowledged the serious breach. The Wound Care Nurse stated that any caregiver should follow the resident's daily care plan located on the back of the resident's door, and confirmed that CNA #3 should have been wearing gloves during the wound care procedure.
The Infection Preventionist expressed severe concern about the employee not wearing personal protective equipment and allowing fingernails to touch the wound. Records showed CNA #3 had completed infection control education in May 2022 and received annual training in July 2023.
A second violation involved improper hand hygiene during wound dressing changes for Resident #82, who suffered from chronic respiratory failure and chronic obstructive pulmonary disease. Like Resident #48, this patient was also on enhanced barrier precautions requiring gowns and gloves during high-contact activities.
Inspectors observed Wound Care Nurse #1 performing a dressing change on July 12, 2024, at 11:10 AM. The nurse removed a soiled dressing from the resident's coccyx area while wearing gloves, then proceeded to cleanse the wound with Vashe wound wash without changing gloves or washing hands.
The nurse continued the procedure with the same contaminated gloves, assessing and measuring the wound before placing sterile dressing materials on the bedside table. Only after completing these steps did the nurse remove the soiled gloves and wash hands before applying skin preparation and wound treatment.
When questioned immediately after the procedure, Wound Care Nurse #1 acknowledged that removing gloves and washing hands after dressing removal was best practice. The nurse admitted to using an improper technique during wound care.
The Infection Preventionist explained the correct protocol during an interview on July 16: nurses should remove soiled dressings, discard them appropriately, then remove soiled gloves, perform hand hygiene, and apply clean gloves before proceeding with the dressing change.
Centers for Disease Control guidelines require healthcare workers to clean their hands after contact with blood, body fluids, or contaminated surfaces. The facility's own handbook, revised in July 2024, states that infection prevention involves handwashing and wearing personal protective equipment when coming in contact with body fluids or contaminated surfaces.
CDC guidelines also specify that natural nails should not extend past the fingertip, raising additional concerns about the artificial nails that contacted Resident #48's wound.
The facility operates under the name Providence Extended Care and markets itself as "The Cottages" in resident materials. Their infection prevention program is described as designed to prevent the spread of infection among residents through proper handwashing and protective equipment use.
Both residents required enhanced barrier precautions due to their medical conditions and vulnerability to infection. Resident #48's diabetes made proper wound care particularly critical, as diabetic patients face increased risks of delayed healing and complications from wound infections.
The wound care violations occurred despite staff completing required infection control training. Records showed the nursing assistant had received both initial and annual education on infection control procedures within the required timeframes.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, but noted they affected multiple residents and created risks for decreased wound healing and compromised resident well-being.
The inspection found that some residents were affected by the facility's failure to implement proper infection prevention and control programs. The violations demonstrate gaps between written policies requiring protective equipment and actual practice during direct patient care.
Polaris Extended Care's policy on abuse prohibition and prevention, revised in January 2024, defines neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The infection control failures could be viewed as falling under this definition by potentially causing physical harm through increased infection risk.
The facility had established protocols requiring enhanced barrier precautions for vulnerable residents, but staff failed to follow these requirements during actual wound care procedures. The violations occurred during routine care activities that happen daily in nursing homes across the country.
Resident #48 remained at risk for wound complications due to the improper infection control practices during his heel ulcer care. His multiple medical conditions, including diabetes and failure to thrive, made him particularly vulnerable to the consequences of contaminated wound treatment.
The nursing assistant's artificial nails touching the wound edges represented a direct breach of infection control standards that could have introduced bacteria into the healing tissue. Such contamination can lead to delayed healing, increased pain, and potentially serious systemic infections in vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Polaris Extended Care from 2024-07-19 including all violations, facility responses, and corrective action plans.