Hammond-Henry District Hospital: Glove Failure - IL
The camera in the resident's room captured everything.
The nursing assistant, identified in the inspection report as V3, entered the room with a second aide to help. What followed was a sequence of more than two dozen distinct actions: lowering the bed, pulling back blankets, removing a pillow from beneath the resident's buttocks, checking for incontinence, rolling up the soiled pad, repositioning the resident, retrieving a clean incontinence brief from the closet, making multiple trips to the bathroom, placing wipes on the bedside table, cleaning the resident's perineal area, wiping and drying the resident's buttocks, tucking the new brief, repositioning the resident, adjusting pillows and blankets and the bed alarm, and finally throwing the gloves in the trash on the way out.
The same gloves. Start to finish.
V3 had touched soiled materials and then touched clean ones. Had handled a dirty incontinence pad and then reached into a closet for a fresh brief. Had cleaned soiled skin and then adjusted pillows the resident would sleep on. The Centers for Disease Control is explicit that gloves should be changed when moving from a soiled body site to a clean one on the same patient, when gloves become contaminated with body fluids, and when they look dirty or carry visible blood or fluid.
V3 was no longer employed at the facility by the time inspectors arrived on October 9 and was not available for interview.
The resident at the center of the video, identified only as R1, was one of three residents whose incontinence care was reviewed. She was the only one whose care showed the violation. The inspection report does not describe her medical history or whether she experienced any infection or other consequence following that night.
What the inspection does describe is what happened when investigators asked the Director of Nursing about it.
At 11:05 a.m. on October 9, the Director of Nursing, identified as V2, would not confirm that V3 should have changed gloves when moving from a soiled surface to a clean one. Instead, according to the inspection report, V2 said the expectation at the facility is that staff perform hand hygiene for five minutes between dirty and clean surfaces.
Five minutes of hand hygiene. Over gloves that are still on.
That response is not consistent with CDC guidance, which the inspection report cites directly. Glove changes are not optional when moving from contaminated to uncontaminated surfaces on the same patient. Hand hygiene, however thorough, does not substitute for removing gloves that have already been soiled.
The inspection was a complaint survey, meaning someone reported a concern before investigators arrived. The violation was tagged at a level of minimal harm or potential for actual harm, which places it at the lower end of the federal harm scale. Inspectors reviewed three residents total for incontinence care practices.
The facility is a district hospital, not a freestanding nursing home, which makes the finding somewhat unusual. Hospital-based long-term care units operate under the same federal infection control standards as standalone facilities.
The incontinence care captured on video lasted long enough, and involved enough contact with soiled materials, that the glove question is not a close call. A nursing assistant moved between a resident's soiled body and clean surfaces, clean linens, a clean brief pulled from a closet, and the pillows and blankets the resident would use for the rest of the night, all without removing the gloves she had put on at the start.
The Director of Nursing, asked directly whether that was wrong, declined to say that it was.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hammond-henry District Hsp from 2025-10-09 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
HAMMOND-HENRY DISTRICT HSP in GENESEO, IL was cited for violations during a health inspection on October 9, 2025.
The camera in the resident's room captured everything.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.