ALS Woodstock: Nurse Skipped Infection Gear - OH
The September 9 incident at ALS Woodstock involved a resident with multiple medical conditions including diabetes, heart disease and a right leg amputation. The patient had developed a chronic wound on their right elbow that required daily dressing changes with specialized materials including collagen and silver alginate.
Licensed Practical Nurse #11 entered the room at 1:30 p.m. and informed the resident about the wound care procedure. She removed the old dressing from the patient's right posterior elbow, discarded it and washed her hands. The nurse cleaned the wound and applied new dressings as ordered, then dated and initialed the bandage before removing her gloves and washing her hands again.
But she never put on a gown.
The resident had been under enhanced barrier precautions since July 22, requiring staff to wear gowns and gloves during high-contact care to prevent transmission of multidrug-resistant organisms. Federal inspectors observed the entire wound care procedure and documented the nurse's failure to use proper protective equipment.
When questioned later that afternoon, LPN #11 admitted she was unaware Resident #19 needed enhanced barrier precautions. She told inspectors the roommate had an infection and assumed the enhanced barrier precautions sign on the door applied only to him.
"The EBP sign on the door of the room did not indicate which resident was in the EBP," the nurse explained to inspectors. She acknowledged she should have worn the required gown during the wound care.
The confusion stemmed from inadequate room signage. The facility posted enhanced barrier precaution signs at room entrances but failed to specify which resident in the double-occupancy room required the additional protections.
Director of Nursing confirmed the signage problem during an interview the following morning. She verified that the enhanced barrier precautions sign at the entrance of Resident #19's room failed to identify which resident needed the special infection control measures.
The nursing director showed inspectors a corrected sign that would be placed on doors of residents requiring enhanced barrier precautions.
Resident #19 had been admitted with an extensive list of medical conditions including rhabdomyolysis, hyponatremia, hypertension, diabetes and a personality disorder. The patient retained full cognitive abilities but required setup assistance for eating and supervision for bed mobility and toileting. Transfers required extensive assistance.
The facility's care plan acknowledged the resident was at risk for skin problems related to diabetic foot ulcers. Planned interventions included administering medications as ordered, monitoring for side effects, assessing and recording wound healing, monitoring nutritional status and providing pressure-reducing devices.
Physician orders specified detailed wound care instructions: cleanse with wound cleanser, pat dry, apply collagen cut to fit the wound bed, add silver alginate cut to fit the wound bed, then cover with bordered foam dressing once daily.
The facility's own policy on enhanced barrier precautions, dated April 1, 2024, defined the protocol as "an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care."
The policy specifically stated enhanced barrier precautions should be initiated for chronic wounds requiring dressings.
Federal inspectors found the facility failed to follow infection control protocol when changing wound dressings, affecting one of three residents they reviewed for wound care. The 42-bed facility received a minimal harm citation for the violation.
The inspection occurred in response to a complaint filed as case number 2597177.
The incident highlighted gaps in communication systems that left nursing staff uncertain about infection control requirements. While the nurse followed proper hand hygiene procedures and applied wound dressings correctly according to physician orders, the failure to wear protective equipment created potential risks for spreading resistant organisms to other residents and staff.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Als Woodstock Inc from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
ALS WOODSTOCK INC in WOODSTOCK, OH was cited for violations during a health inspection on September 10, 2025.
The September 9 incident at ALS Woodstock involved a resident with multiple medical conditions including diabetes, heart disease and a right leg amputation.
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.