The incident at Greater Southside Health and Rehabilitation involved two residents with open wounds who required enhanced barrier precautions — infection control measures designed to prevent the spread of dangerous bacteria in vulnerable populations.
During the August 27 observation, Staff D, a licensed practical nurse, and Staff E, a nurse practitioner, treated Resident 11 who had a right lateral foot wound. The resident lay in bed as Staff D removed foam boots and peeled away a dressing dated three days earlier.
Staff E then took a scalpel and debrided wounds on the resident's right lateral foot and left inner ankle. Staff D cleansed the wound areas and applied calcium alginate and a silicone foam dressing before labeling the new dressing with the date and initials "KW."
Neither nurse wore a gown during the treatment.
The facility's own physician orders from August required enhanced barrier precautions for this resident's wound care, specifying that staff must wear both gowns and gloves during "high contact care activities."
Thirty minutes later, inspectors observed Staff D treating another resident with similar protocol violations.
Resident 9, who had quadriplegia and wounds on both heels, also required enhanced barrier precautions according to physician orders dating to May 14. The orders specifically cited the resident's wounds and indwelling medical device as requiring gown and glove use.
Staff D gathered supplies from a treatment cart, sanitized her hands, and put on gloves before entering the room. She used gauze soaked in wound cleanser to clean wounds on the resident's left and right heels, then applied betadine, large dressings, and kerlix wrap to each wound.
But Staff D never wore a gown during the procedure. She also failed to change gloves or sanitize her hands when moving between dirty and clean tasks during the treatment.
The facility's care plan for Resident 9, revised in January, specifically directed staff to "use enhanced barrier precautions" while providing wound treatments per physician orders.
When interviewed the next day, Staff A, a certified nursing assistant, correctly explained that enhanced barrier precautions "entailed wearing a gown and gloves during high contact activities" and should be used "whenever wound care or catheter care performed, or if a resident had an infection."
The Director of Nursing told inspectors he expected enhanced barrier precautions "anytime staff took care of a resident who had a catheter or a wound." He said staff should wear both gowns and gloves, and "gloves changed whenever staff removed a dressing and anytime going between steps or a clean area."
The nursing director added that staff should "change gloves and sanitize their hands, then put a clean dressing on."
The facility's own infection control policy, reviewed in August 2024, outlined the medical reasoning behind the requirements. Enhanced barrier precautions work "in conjunction with standard precautions" and expand protective equipment use "during high-contact resident care activities" specifically because of "the high risk of acquisition and colonization of Multi-Drug Resistant Organisms."
The policy required that personal protective equipment be "donned upon room entry, then doffed and properly discarded, and hand hygiene performed before exiting the room to contain pathogens."
Multi-drug resistant organisms pose particular dangers in nursing home settings, where residents often have compromised immune systems, open wounds, and medical devices that create pathways for infection.
The inspection found that despite clear physician orders, facility policies, and staff knowledge of proper procedures, nurses consistently skipped required protective equipment during wound care procedures.
Both residents involved had conditions that made them especially vulnerable to infection — one with multiple wounds requiring surgical debridement, another with quadriplegia and bilateral heel wounds requiring daily cleaning and dressing changes.
The violations occurred during routine wound care that both residents required regularly, suggesting the protocol failures were part of ongoing practice rather than isolated incidents.
Federal inspectors classified the violations as having caused "minimal harm or potential for actual harm" to residents, though the facility's own policies acknowledged the "high risk" that improper infection control creates for dangerous bacterial colonization in vulnerable patients.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greater Southside Health and Rehabilitation from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
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