The violation occurred during an 11-minute wound treatment session at Omaha Nursing and Rehabilitation Center on October 7, when state inspectors observed Licensed Practical Nurse A treating wounds on Resident 2's thighs and heel.
The nurse began properly, washing her hands with soap and water for 32 seconds before putting on a gown and gloves. She washed the resident's right and left posterior thighs, then removed her gloves.
Without washing her hands, she put on new gloves and washed the resident's right posterior heel. She removed those gloves and again put on new ones without hand hygiene, this time to perform the actual wound treatment on the heel.
The pattern continued. After finishing the heel treatment, she removed gloves and put on another pair without washing to treat the thigh wounds. Then she removed those gloves, put on yet another pair without hand washing, and returned to re-apply treatment to the heel wound.
Only at the end of the entire procedure did the nurse wash her hands before leaving the room.
The facility's own hand hygiene policy, revised in October 2022, explicitly required staff to perform alcohol-based hand rubs containing at least 62 percent alcohol or wash with soap and water "before moving from a contaminated body site to a clean body site during resident care" and "after removing gloves."
When inspectors interviewed the nurse immediately after the wound care session, she acknowledged she had not performed hand hygiene between glove changes and confirmed she should have.
The violation represents a fundamental breakdown in infection prevention during wound care, when residents are most vulnerable to contamination. Moving between different wound sites on the same person without proper hand hygiene can transfer bacteria from one area to another, potentially causing new infections or complicating existing ones.
Omaha Nursing and Rehabilitation Center houses 50 residents. State inspectors conducted the observation as part of a complaint investigation, suggesting someone had raised concerns about infection control practices at the facility.
Hand hygiene violations in nursing homes have drawn increased scrutiny from federal regulators, particularly after the COVID-19 pandemic highlighted how quickly infections can spread in congregate care settings. The Centers for Disease Control and Prevention has identified proper hand washing as the single most important measure for preventing healthcare-associated infections.
The facility's detailed policy showed administrators understood the requirements. Staff were supposed to use alcohol-based hand sanitizer or soap and water not just before handling clean dressings and after removing gloves, but specifically "before moving from a contaminated body site to a clean body site."
Yet during the observed wound care session, the nurse moved from treating thigh wounds to heel wounds and back again multiple times, each transition creating an opportunity for cross-contamination that proper hand hygiene could have prevented.
The inspection classified the violation as causing "minimal harm or potential for actual harm," but infection control experts note that such breaches can lead to serious complications for elderly residents whose immune systems may already be compromised.
The state cited the facility under federal regulation F 0880, which requires nursing homes to "provide and implement an infection prevention and control program." The citation indicates the facility failed to ensure its staff followed basic infection prevention protocols during direct patient care.
Resident 2's specific medical condition was not detailed in the inspection report, but the presence of wounds on both thighs and the heel suggests someone dealing with multiple pressure sores or other skin breakdown issues common among nursing home residents with limited mobility.
The 11-minute treatment window observed by inspectors captured a routine care interaction that likely occurs daily for many residents at the facility. If such fundamental infection control lapses are occurring during basic wound care, it raises questions about adherence to protocols during other high-risk procedures.
The nurse's immediate acknowledgment that she should have washed her hands between glove changes suggests the violation stemmed from poor practice rather than lack of knowledge about requirements.
For families of nursing home residents, the incident highlights the importance of infection prevention protocols that may seem routine but can significantly impact their loved ones' health outcomes when not properly followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Omaha Nursing and Rehabilitation Center from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
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