Blumenthal Health and Rehab: Infection Control Failures - NC
Inspectors were present in the room on September 11, 2025, and watched the entire thing.
The resident, identified in inspection records only as Resident 9, had both a sacral wound requiring dressing changes and a colostomy. A yellow sign on her doorway told every staff member who entered that she was on enhanced barrier precautions, meaning a gown and gloves were required before any wound care or toileting assistance. The sign was visible. The nurse, identified as Nurse 9, told inspectors afterward that she knew the resident was on enhanced barrier precautions. She said she couldn't find the cart that held the protective equipment.
She never looked for it.
What inspectors watched instead was a sequence of breaks in basic infection control, one after another, over the course of a single care session. Nurse 9 removed the soiled dressing from the resident's sacral wound and threw it away. She took off her gloves and washed her hands, then put on a clean pair. So far, correct. Then, without changing gloves, she reached into an open package of gauze to retrieve more, contaminating whatever gauze remained. She threw the rest of the package in the trash.
Then the glove changes began in earnest, and the hand washing stopped keeping pace with them.
Nurse 9 removed her gloves and put on a new pair without washing her hands. She applied collagen to the wound, removed those gloves, and put on another pair, again without washing her hands. She applied a hydro fiber dressing with silver, removed those gloves, then donned yet another pair, again without washing her hands, before applying the final bordered gauze dressing to complete the wound care.
When inspectors interviewed her twenty minutes after the observation, Nurse 9 said she washed her hands "plenty of times" during the wound care session. She said she was not aware she had failed to wash between glove changes.
The colostomy care came separately, and added its own problem. Nurse 9 removed a pair of scissors from her pocket, cut the ostomy wafer to the correct size, and pressed the new appliance against the resident's skin, bare-handed, without gloves. After finishing, she put the scissors back in her pocket. When asked about the scissors, she said they hadn't touched anything dirty, so she didn't think cleaning them was necessary.
The Unit Manager, interviewed the same afternoon, said staff were expected to wear the PPE listed on the door sign, wash hands between glove changes, and clean any instruments used during ostomy care. The Director of Nursing, reached a few hours later, said Nurse 9 should have worn the correct protective equipment before entering the room, used a proper barrier when handling wound care supplies, and never applied an ostomy appliance with bare hands. The facility's Infection Preventionist, interviewed the following day, said the same, and added one detail that sharpened the picture: using bare hands to press an ostomy appliance against a patient's skin, on a resident already flagged for enhanced barrier precautions, should not have happened under any circumstances.
Each of those supervisors described, clearly and without qualification, exactly what Nurse 9 should have done. None of what they described had occurred.
The inspection was prompted by a complaint and carried a harm level CMS classified as minimal harm or potential for actual harm, affecting few residents. The classification reflects the regulatory floor, not a medical judgment about what happens when contaminated scissors go back into a pocket, or when a nurse's ungloved hands make contact with an open ostomy site on a patient whose door sign exists precisely because her infection risk is elevated.
Resident 9 was in that room when all of it happened. She had a wound that needed to heal.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Blumenthal Health and Rehabilitation Center from 2025-09-13 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.
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 20, 2026 · Our methodology
Blumenthal Health and Rehabilitation Center in Greensboro, NC was cited for violations during a health inspection on September 13, 2025.
Inspectors were present in the room on September 11, 2025, and watched the entire thing.
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.