East Lake Arbor: Infection Control Failures, GA
DECATUR, GA - State inspectors found that wound care staff at The Crossings at East Lake failed to follow basic hand hygiene protocols while treating a resident with a severe stage 4 pressure ulcer, potentially exposing the vulnerable patient to infection risks.
Serious Infection Control Breach Documented
During an unannounced inspection on January 8, 2025, state surveyors observed a wound care nurse treating a resident's stage 4 sacral pressure ulcer without following established hand hygiene protocols. The nurse was observed removing contaminated gloves and immediately putting on new gloves without sanitizing her hands between the glove changes.
The resident receiving care had intact mental capacity and was dealing with a stage 4 pressure ulcer - the most severe category of pressure wound that extends through all layers of skin and into underlying muscle, bone, or supporting structures. These deep wounds require meticulous care to prevent life-threatening infections.
According to the facility's own policy dated February 1, 2024, "All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors." The policy specifically states that "the use of gloves does not replace hand hygiene" and requires staff to "perform hand hygiene prior to donning gloves, and immediately after removing gloves."
Medical Significance of Hand Hygiene Failures
Hand hygiene represents the single most important measure for preventing healthcare-associated infections. When caring for open wounds, particularly deep pressure ulcers, proper hand sanitization creates a critical barrier against bacterial contamination that can lead to serious complications.
Stage 4 pressure ulcers already present significant infection risks due to their depth and exposure of underlying tissues. These wounds can develop osteomyelitis (bone infection), sepsis (bloodstream infection), or other life-threatening complications if bacteria are introduced during care procedures.
The contaminated gloves that the nurse wore while handling wound materials could harbor dangerous microorganisms including methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, or other pathogens common in healthcare settings. Without proper hand hygiene, these organisms can transfer from the contaminated glove surface to clean gloves and ultimately to the wound site.
Staff Acknowledgment of Protocol Failures
When questioned by inspectors, the wound care nurse acknowledged her error. "She stated she should have sanitized her hands in between glove change to prevent the spread of germs to R64," according to the inspection report. The nurse further admitted that "the resident could get an infection if she did not sanitize her hands after removing her gloves and before putting on a new pair of gloves."
The unit manager confirmed proper protocols during her interview, explaining that staff should sanitize their hands before entering resident rooms, while providing care, after removing gloves, and before putting on new gloves. She warned that failure to follow hand hygiene procedures "would be the residents could get infections."
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
CROSSINGS AT EAST LAKE OF JOURNEY LLC, THE in DECATUR, GA was cited for violations during a health inspection on January 9, 2025.
The nurse was observed removing contaminated gloves and immediately putting on new gloves without sanitizing her hands between the glove changes.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.