The violations occurred on August 21 during federal inspectors' complaint investigation at The Oaks Healthcare Center, where 18 residents had active wounds and 27 required enhanced barrier precautions.
LPN #1 began wound care for Resident #2 at 9:26 a.m., properly donning gloves and a gown before positioning the resident and removing the current dressing. But when the nurse needed additional supplies, they removed only their gloves and left the room wearing the same gown.
The nurse returned wearing the contaminated gown and continued the wound care procedure. When more supplies were needed again, LPN #1 repeated the same violation — removing gloves but keeping the same gown while exiting and reentering the room.
Resident #2 suffered from atherosclerosis with leg ulceration, diabetes, and moderate malnutrition. Medical records showed the resident had intact cognition and required daily wound care to bilateral lower extremities every Tuesday. The physician's orders specified a complex treatment protocol: cleanse with normal saline, apply gentamicin for skin infections, pack with iodoform antiseptic, cover with gauze, then apply three layers of compression wrapping.
When questioned at 9:45 a.m., LPN #1 stated they knew the correct process was to remove and dispose of personal protective equipment in the hallway barrel.
The same nurse violated infection protocols again that morning while treating Resident #3 at 9:00 a.m. No warning signage was posted at the door, and no protective equipment was available outside the room as required by facility policy.
LPN #1 gathered supplies from their cart and entered wearing only gloves — no gown at all. The nurse positioned the resident, removed the existing dressing, changed gloves, used hand sanitizer, and completed the entire wound care procedure without wearing the required gown.
Resident #3 had multiple serious conditions including osteoarthritis, thrombocytopenia, severe malnutrition, and cerebrovascular disease. A significant change assessment from August 10 documented severe cognitive impairment and one unstageable pressure ulcer on the left hip.
The resident's physician orders required daily cleaning of the left hip wound with saline or wound cleanser, packing with iodoform, and covering with bordered foam dressing.
At 9:15 a.m., LPN #1 acknowledged to inspectors that "all residents with wounds should be on enhanced barrier precautions." The nurse stated they "had forgot."
The facility's own Enhanced Barrier Precautions Policy required orders for any residents with wounds. The policy mandated making gowns and gloves immediately available near or outside residents' rooms, and positioning trash cans inside rooms for discarding protective equipment before exiting or providing care to another resident in the same room.
Federal inspectors documented these violations as part of a complaint investigation, finding the facility failed to maintain proper infection prevention and control programs for two of three sampled residents reviewed for enhanced barrier precautions.
The violations occurred despite clear facility policies and physician orders specifying the complex wound care requirements for both residents. Resident #2's diabetic complications and Resident #3's severe malnutrition made proper infection control particularly critical.
Both residents required ongoing daily wound care with multiple steps involving antiseptics, antibiotics, and specialized dressing materials. The contaminated gown and missing protective equipment created infection risks during these vulnerable medical procedures.
The nurse's admission of forgetting required precautions for wound patients highlighted systemic gaps in the facility's infection control implementation, particularly concerning given that 18 residents had active wounds requiring enhanced barrier precautions at the time of inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Oaks Healthcare Center from 2025-08-21 including all violations, facility responses, and corrective action plans.