The facility's Director of Nursing and Licensed Practical Nurse #200 also failed to wear required protective gowns while caring for Resident #16, who was under enhanced barrier precautions following surgical drainage of a scrotal abscess in August.
Inspectors observed the violation during wound care on September 26. LPN #200 assisted with the procedure while wearing only protective gloves, touching the resident's tray tables, sheets, and bed. She then reached into a bottle of Iodoform gauze with the same contaminated gloves and pulled out sterile dressing material, which she handed to the Director of Nursing.
The Director of Nursing packed the Iodoform directly into Resident #16's surgical wound using a cotton swab, completing the entire procedure without either nurse wearing the required protective gowns.
Resident #16 had been admitted to the 55-bed facility in October 2020 following a stroke that left him with paralysis on one side of his body. He also had epilepsy and scrotal cellulitis. Hospital records from August 15 show surgeons performed an exploration of his scrotum, draining a large abscess and removing dead tissue before packing the wound with wet-to-dry Iodoform gauze.
A physician's order from February required staff to wear gloves and gowns when providing treatment or care to Resident #16 under enhanced barrier precautions. Another order from September 25 specified daily packing of the wound with Iodoform gauze strips for 20 days.
The facility had posted the required warning sign on Resident #16's door frame. The white magnetic sign displayed "EBP" at the top with pictures showing proper handwashing technique, a protective gown, and gloves.
When inspectors interviewed both nurses immediately after the wound care procedure, the Director of Nursing and LPN #200 acknowledged they had failed to wear gowns. They also confirmed they had not maintained proper infection control by using the same gloves to touch contaminated surfaces and handle clean wound dressing materials without washing their hands or changing gloves between tasks.
The facility's own policy, last revised in August 2022, specifically requires enhanced barrier precautions for residents with wounds. The policy states that hand washing, gloves, and gowns should be worn during high-contact resident care, which explicitly includes wound care for any skin opening requiring a dressing.
The policy also requires signage at room entrances to alert staff and visitors to consult with nurses before entering, so they can receive proper instruction on personal protective equipment requirements.
Resident #16 remained cognitively intact throughout his stay, according to his most recent assessment, meaning he was likely aware of the infection control failures during his daily wound care. His surgical wound required careful handling to prevent complications as the deep scrotal tissue healed from the August drainage procedure.
The contamination occurred during a procedure that required direct contact with an open surgical site in an area already prone to bacterial infection. Scrotal wounds present particular infection risks due to their location and the difficulty of maintaining sterile conditions during healing.
Federal inspectors determined the infection control violations caused minimal harm but created potential for actual harm to Resident #16. The failures occurred despite clear physician orders, posted warning signs, and the facility's own written policies requiring protective equipment and sterile technique.
The investigation stemmed from a complaint filed against the facility. Inspectors reviewed medical records for three residents with wounds but found violations affecting only Resident #16's care.
Both nurses involved in the September 26 wound care procedure held positions requiring knowledge of basic infection control principles. The Director of Nursing oversees all clinical care at the facility, while Licensed Practical Nurse #200 provides direct patient care under supervision.
The facility failed to follow its own isolation precautions process, which was designed to prevent exactly this type of cross-contamination during wound care procedures for vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Otterbein Monclova from 2025-09-26 including all violations, facility responses, and corrective action plans.