The violations occurred during wound care for a resident placed on enhanced barrier precautions, a heightened infection control protocol designed to prevent the spread of resistant organisms.
Staff B, a registered nurse, committed multiple infection control breaches during an 11:30 AM wound care session on October 19. After examining three wounds on the resident's right lower shin that appeared dark purple with large amounts of drainage, the nurse left the room wearing an isolation gown without washing her hands.
The nurse returned two minutes later and donned new protective equipment, but then dried all three wounds using the same piece of gauze. Without changing gloves or washing hands, Staff B opened three new collagen dressing packets and applied them to the wounds.
At 11:42 AM, Staff B removed scissors from her pocket and cut dressings from the resident's left lower leg without first disinfecting the instruments. The removed dressings were dated October 19 and saturated with wound drainage.
The contamination continued as Staff B cleansed wounds on the left leg with the same gauze used on the right leg wounds. Without changing gloves or performing hand hygiene, the nurse opened three more collagen dressing packets and then picked dead skin from one of the wounds with contaminated gloves.
Staff B removed the gloves and put on new ones without washing hands first. The nurse then cleansed a wound on the resident's left second toe without changing gloves again.
The final breach occurred when Staff B picked up items from the floor and, without changing gloves, placed new dressing supplies in a drawer by the sink. The scissors were also placed in the drawer without disinfection.
During interviews, both nurses involved demonstrated knowledge of proper protocols but admitted to multiple failures.
Staff A, another registered nurse, told inspectors on October 20 that proper protocol required changing gloves after removing soiled dressings, after touching surfaces, and after cleansing wounds. She said scissors must be disinfected before and after cutting dressings.
Staff A also revealed she had performed wound care on the same resident three days earlier at the nurse's station rather than in his room, concerned that wound drainage would cause his pants to stick to his skin. She admitted she may not have worn gloves while taping dressings in place and took soiled dressings outside to the dumpster in a clear bag.
Staff B acknowledged during her October 20 interview that dressing changes should occur in residents' rooms and that gloves must be changed after touching contaminated surfaces. She admitted forgetting to disinfect scissors after wound care but could not explain why.
When asked about proper wound cleansing technique, Staff B correctly stated wounds should be cleaned "up and down and away from the wound," demonstrating awareness of protocols she had failed to follow.
The Director of Nursing confirmed expectations during her October 21 interview. For residents on enhanced barrier precautions, she said nurses must complete wound care in the resident's room, properly don and remove isolation gowns and gloves within the room, cleanse wounds from center outward, and disinfect scissors before and after each dressing change.
Facility policies supported these expectations but contained gaps. The June 2025 Wound Care Guidelines required hand washing, glove changes, and disinfection of reusable supplies "as indicated," but failed to specify the direction nurses should take when cleansing wounds.
The October 2024 Standard Precautions policy directed staff to don isolation gowns before care and remove them with hand hygiene before leaving residents' rooms.
The inspection found that established protocols existed but were not consistently followed, creating potential for cross-contamination and infection spread among vulnerable residents requiring enhanced protective measures.
Federal inspectors classified the violations as having minimal harm or potential for actual harm affecting few residents, but the breaches occurred during care for a resident specifically identified as needing heightened infection control precautions due to resistant organisms or other high-risk conditions.
The case illustrates how basic infection control failures can compound during routine care, with a single nurse committing multiple protocol violations during one 27-minute wound care session while supervisors remained unaware of the practices occurring at bedside.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aspire of Pleasant Valley from 2025-10-21 including all violations, facility responses, and corrective action plans.