Summers Healthcare Center: Infection Control Failures - WV
The nurse, identified in inspection records as LPN #16, was treating pressure ulcers on a resident's left hip and left buttock on the afternoon of August 13. The resident, identified as Resident #43, had open wounds requiring dressing changes and was also incontinent of stool during the procedure.
LPN #16 removed the dressing from the hip wound and changed gloves. No hand hygiene. He cleaned the wound and changed gloves again. No hand hygiene. He applied the new dressing and changed gloves. No hand hygiene. He then performed incontinence care, wiping fecal matter and changing the resident's brief, and changed gloves again. No hand hygiene. He moved to the buttock wound, removed the old dressing, changed gloves, cleaned the wound, and changed gloves one final time. Still no hand hygiene. Only after the entire procedure was finished did he use hand sanitizer.
When inspectors questioned him, LPN #16 acknowledged he had not performed hand hygiene when changing gloves during the dressing changes or after the incontinence care.
The same resident was already under enhanced barrier precautions because of an indwelling urinary catheter and open wounds. Six days after the observed dressing changes, on August 19, a physician ordered contact isolation for the resident after diagnosing an extended-spectrum beta-lactamase infection of the urinary tract. ESBL bacteria are resistant to many common antibiotics.
A sign outside the room was updated to reflect contact isolation status, requiring all staff to gown and glove before entering. The next morning, at 9:00 AM on August 20, a nursing assistant was observed sitting beside the resident's bed, feeding the resident, with no gown and no gloves. When asked, Nursing Assistant #109 said she hadn't noticed the sign had changed from enhanced barrier precautions to contact isolation.
She said she didn't know.
The second resident flagged in the inspection report had been in contact isolation since August 8, diagnosed with Clostridioides difficile. C. diff is a bacterial infection that spreads through spores capable of surviving on surfaces for months. The sign outside that resident's room specified that anyone entering must gown and glove, use hand sanitizer upon entering, and wash with soap and water upon leaving, because C. diff spores are not killed by hand sanitizer.
On August 19 at approximately 1:00 PM, Nursing Assistant #82 carried a lunch tray into the room wearing neither a gown nor gloves. She set up the meal tray. She touched the resident's shoulder. She touched the wheelchair. She touched the bed controls. When she left, she used the hand sanitizer in the hallway instead of washing with soap and water.
When inspectors asked her about it, NA #82 said the precautions only applied to resident care, not to delivering a food tray.
The Director of Nursing confirmed that afternoon that contact enteric precautions applied to every staff member who entered the room, for any reason.
The inspection was conducted as a complaint survey. Inspectors reviewed three residents for transmission-based precaution compliance and found problems with two of them. They observed two dressing changes and found hand hygiene failures in one.
Summers Healthcare Center, located at 198 John Cook Nursing Home Road, had a census of 102 residents at the time of the inspection. The facility's own skills checklist for dressing changes instructs staff to perform hand hygiene after removing soiled gloves and before donning new ones. Its standard precautions policy specifically addresses moving from a contaminated body site to a clean one as a moment requiring hand hygiene.
LPN #16 moved from fecal matter to open wounds. He changed his gloves and kept going.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Summers Healthcare Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
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.
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Last verified: October 13, 2026 · Our methodology
SUMMERS HEALTHCARE CENTER in HINTON, WV was cited for violations during a health inspection on August 20, 2025.
The nurse, identified in inspection records as LPN #16, was treating pressure ulcers on a resident's left hip and left buttock on the afternoon of August 13.
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.