State inspectors found these infection control violations during a September complaint investigation at Oak View Home, documenting failures that put residents at risk of cross-contamination.
The nursing director's lapse occurred during wound care for a resident admitted with multiple conditions including a stage 3 pressure ulcer. Medical orders required cleaning the resident's right lower leg with saline, applying collagen dressing, and covering it with a border dressing three times weekly.
During the 10:04 a.m. treatment on September 17, inspectors watched the director of nursing remove her gloves and put on a new pair without washing her hands between the dirty and clean dressing changes. When interviewed 21 minutes later, she confirmed skipping the hand hygiene step.
The facility's own policy, revised just eight months earlier, explicitly required hand hygiene "immediately after glove removal" and stated that "gloves should not substitute for hand hygiene, and hand hygiene must be performed before donning gloves and immediately after removing gloves."
A wound care consultant interviewed that evening confirmed hand hygiene was required between glove changes.
The second violation involved routine clothing delivery that became a potential infection pathway. On September 16 at 12:14 p.m., inspectors observed a laundry aide delivering clean clothing to three residents' rooms on Hall B without performing hand hygiene when entering or exiting any room.
The aide acknowledged her failure four minutes later when interviewed. She said she "just forgot" despite signs posted throughout the facility reminding staff to perform hand hygiene.
The facility's hand hygiene policy required staff to clean their hands "immediately before touching a patient" and "after touching a patient or the patient's immediate environment." The policy also mandated hand cleaning "before moving from a soiled body site to a clean body site" and "after contact with blood or contaminated surfaces."
These weren't isolated incidents affecting single residents. The laundry aide's failure potentially exposed three residents on Hall B to cross-contamination from room to room. The nursing director's lapse occurred during direct wound care for a resident with an open stage 3 pressure ulcer.
Stage 3 pressure ulcers involve full-thickness skin loss extending into subcutaneous tissue. The resident's wound required specialized collagen treatment and careful sterile technique to prevent infection.
The violations represented basic infection control failures by two different staff members on consecutive days. One involved the facility's top nursing administrator during complex wound care. The other involved routine clothing delivery that should require minimal training to perform safely.
Hand hygiene serves as the primary barrier against healthcare-associated infections in nursing homes. The Centers for Disease Control identifies proper hand washing as the single most important measure for preventing the spread of infection among vulnerable elderly residents.
Oak View Home's policy acknowledged this reality by requiring hand hygiene before and after patient contact, before sterile procedures, and after removing gloves. The policy specifically stated that gloves don't substitute for proper hand washing.
Yet inspectors found the director of nursing violated these requirements during wound care for a resident with an open ulcer. They also documented a laundry aide ignoring hand hygiene protocols while moving between multiple resident rooms.
The inspection report classified both violations as having "minimal harm or potential for actual harm" but noted they placed residents at risk of infection through cross-contamination. Few residents were directly affected by the specific incidents observed.
However, the failures occurred at different levels of the facility's staffing hierarchy and involved both clinical and support services. The director of nursing's violation during wound care represented a particularly serious lapse given her leadership role and the vulnerable nature of the resident receiving treatment.
The resident requiring wound care had been living at Oak View Home since earlier in 2025. Medical orders dating to July specified the complex dressing changes needed to treat the stage 3 pressure ulcer on the right lower leg.
Inspectors documented their observations in real time, watching the director of nursing perform the entire wound care procedure. The violation occurred at the critical moment when contaminated gloves were removed and clean ones applied without the required hand hygiene step.
The laundry aide's admission that she "just forgot" to wash her hands suggested the violation resulted from inattention rather than deliberate disregard for policy. But the impact remained the same: potential cross-contamination between resident rooms during routine clothing delivery.
Both staff members worked at a facility where hand hygiene reminders were posted throughout the building, according to the laundry aide's interview. The director of nursing would have been responsible for ensuring compliance with the infection control policies she violated.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak View Home, Inc from 2025-09-18 including all violations, facility responses, and corrective action plans.