The resident, identified as R1 in the October inspection report, had multiple serious conditions including spina bifida, paraplegia, severe sepsis, and the stage 4 sacral pressure ulcer. A sign posted outside the resident's door clearly indicated staff should wear gowns and gloves during high-contact care, including wound treatment.
Federal inspectors observed the violation during a 10 a.m. wound care session at Marquardt Memorial Manor. Licensed practical nurse LPN-C and certified nursing assistant CNA-D entered the room without gowns, despite the posted requirements.
The contamination began immediately. LPN-C placed gauze packages, wound cleanser, and bandage scissors directly on the resident's bedside table without disinfecting the surface or using a protective barrier. During the wound care, both staff members' clothing contacted the resident's bed linens and environment.
The infection control failures multiplied throughout the procedure. LPN-C removed gloves after completing the soiled portion of wound care but failed to sanitize hands before applying a clean dressing. The nurse's bare right hand then touched the resident's skin, linens, and environment while using tape.
LPN-C placed unused dressing packages on the contaminated bedside table and retrieved clean gloves from the treatment cart without completing hand hygiene. The nurse removed gloves, handled tape with bare hands, and stuck the tape to a second bedside table before donning new gloves to continue treatment.
After completing the wound care, LPN-C rolled the treatment cart to the nurses' station. The cart contained the contaminated bandage scissors and wound cleanser that had been placed on the resident's bedside table without barriers.
At 10:59 a.m., LPN-C attempted to disinfect the scissors, wound cleanser, and cart top using hydrogen peroxide-based wipes. However, the nurse was unaware the disinfecting product required a one-minute dwell time to work properly and put the items back in the cart before ensuring adequate contact time.
When interviewed at 11:03 a.m., LPN-C initially thought gowns had been worn during the wound care and stated being nervous during the procedure. The nurse acknowledged the treatment cart is used for all residents and confirmed sanitizing the cart after leaving each room.
LPN-C verified that wound care items should have been placed in a treatment bag rather than loose in the shared cart. The nurse also acknowledged that gowns should have been worn because the resident had an open wound and a Foley catheter.
CNA-D's response was more direct when interviewed at 11:30 a.m. When asked about wearing gowns during care for R1, the aide stated, "Sometimes, sometimes not." CNA-D then added, "We just forgot to put one on, I think."
Director of Nursing DON-B confirmed during a 3 p.m. interview that both staff members should have worn gowns during wound care for the resident. DON-B also indicated LPN-C should have taken only the needed amount of gauze and placed it on a clean surface with a barrier.
When informed about the missed hand hygiene opportunities and cross-contamination of wound care products, clothing, and the environment, DON-B stated the facility had educated staff on infection control. The director verified that items used in the resident's room should not be used on other residents, including the contaminated tape and gauze.
The resident receiving the inadequate wound care had intact cognition with a Brief Interview for Mental Status score of 14 out of 15, meaning they were fully aware of their treatment and responsible for their own healthcare decisions.
The violations occurred despite clear facility protocols. The Enhanced Barrier Precautions sign posted outside the resident's door specifically indicated staff should wear gowns and gloves during high-contact resident care, including wound care.
The contaminated treatment cart and supplies were used throughout the facility on other residents following the observed violations. The bandage scissors and wound cleanser that had been placed on contaminated surfaces without barriers were returned to the shared cart for use in subsequent patient care.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, affecting few residents. The inspection was conducted in response to a complaint filed against the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marquardt Memorial Manor from 2025-10-06 including all violations, facility responses, and corrective action plans.