The September 15 incident at Signature Healthcare of Galion involved a resident with Alzheimer's disease who had suffered a skin tear on her right lower leg. The 2.5-centimeter wound was nearly an inch wide and required specialized dressing changes every three days.
Assistant Director of Nursing #260 placed the dirty dressing on a paper towel sitting on the resident's over-bed table. She then cleaned the wound and squeezed Vitamin A and D ointment onto the tip of her index finger, applying it directly to the open skin tear while wearing the same gloves she had used to handle the contaminated dressing.
When questioned immediately after the procedure, the nursing director acknowledged she had not removed her gloves, performed any hand hygiene, or changed to clean gloves before touching the wound with her finger.
The resident affected by the infection control violation has severe cognitive impairment from Alzheimer's disease, along with type 2 diabetes, major depressive disorder, and chronic kidney disease. Her medical conditions make her particularly vulnerable to infection complications.
Federal inspectors observed the improper wound care during an unannounced visit to investigate complaints at the 51-bed facility. The violation directly contradicted the nursing home's own wound care policy, which explicitly requires staff to discard contaminated gloves and wash hands between removing old dressings and applying new treatments.
The facility's September 2021 wound care policy states that after loosening tape and removing dressings, staff should "pull the glove over the dressing and discard into appropriate receptacle" before washing and drying hands thoroughly and putting on fresh gloves. Only then should wounds be cleaned and treatments applied as ordered by physicians.
The resident's skin tear had been documented eight days earlier in a wound evaluation note. The injury measured 2.5 centimeters long, 0.8 centimeters wide, and 0.1 centimeters deep. Her physician had ordered the wound to be cleansed with normal saline or wound cleanser, treated with the vitamin ointment, and covered with Dermaview II, a specialized transparent dressing designed to prevent bacterial contamination.
The contamination risk was particularly concerning given the resident's diabetes, which can significantly impair wound healing and increase infection susceptibility. Diabetic patients face heightened risks of serious complications from wound infections, including potential amputation in severe cases.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm," but noted it affected infection control practices that are fundamental to preventing healthcare-associated infections in vulnerable nursing home populations.
The assistant nursing director's actions violated basic infection control principles designed to prevent cross-contamination between dirty and clean surfaces. By using contaminated gloves to apply medication directly to an open wound, she potentially introduced harmful bacteria from the soiled dressing into the resident's healing tissue.
Signature Healthcare of Galion houses 51 residents, many with complex medical conditions requiring specialized care protocols. The facility's failure to follow its own infection prevention procedures during wound care raises questions about staff training and supervision of critical nursing tasks.
The inspection found that only one of two residents observed for infection control practices was affected by improper procedures, suggesting the violation may have been an isolated incident rather than systematic neglect of protocols.
However, the involvement of the assistant director of nursing in the violation is particularly troubling, as this administrator would typically be responsible for training and supervising other staff members in proper infection control techniques.
The contaminated glove incident occurred during routine wound care that should have been straightforward to perform correctly. The resident's treatment plan called for simple cleansing, ointment application, and dressing replacement every three days, procedures that nursing staff perform regularly throughout healthcare facilities.
Instead, the assistant nursing director's failure to follow basic hand hygiene and glove-changing protocols potentially exposed a cognitively impaired, diabetic resident to preventable infection risks during what should have been protective wound care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare of Galion from 2025-09-16 including all violations, facility responses, and corrective action plans.
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