Glenburnie Rehab: Infection Control Failure Cited - VA
Federal inspectors visited Glenburnie Rehab & Nursing Center on October 28, 2025, and watched licensed practical nurse #2, the facility's designated wound nurse, prepare to treat a resident identified in records as Resident 2. The resident had chronic wounds and a Foley catheter, a tube inserted into the urethra to drain urine from the bladder. Both conditions placed the resident at elevated risk for carrying or acquiring multidrug-resistant organisms, the kind of bacteria that standard antibiotics can no longer reliably kill.
Nothing about the scene suggested anyone had flagged that risk. No isolation signage was posted outside the room. No gown or gloves were visible. The nurse entered and performed wound care without putting on any protective equipment.
Inspectors then pulled the resident's clinical record. The resident had been admitted 47 days earlier. There were no orders for enhanced barrier precautions anywhere in the file, and no evidence those precautions had ever been used.
Enhanced barrier precautions require staff to wear a gown and gloves during high-contact care activities, including wound care, for residents with chronic wounds or indwelling medical devices like catheters. The precautions are designed specifically to stop multidrug-resistant bacteria from moving from one resident's body to a caregiver's hands or clothing, and from there to the next resident that caregiver touches.
The facility had its own written policy on this. It said employees providing high-contact care for patients with chronic wounds or indwelling medical devices will follow enhanced barrier precautions. The policy named wound care explicitly. None of it had been applied to this resident at any point during a stay that had already stretched past six weeks.
The following morning, inspectors interviewed the director of nursing and the regional director of clinical operations. The director of nursing said enhanced barrier precautions exist to prevent the spread of harmful bacteria from resident to resident. The regional director of clinical operations said the precautions are triggered when any resident has a chronic wound or an invasive device such as a Foley catheter. Both administrators described, accurately, exactly the situation their facility had failed to address for a month and a half.
The administrator and director of nursing were informed of the findings later that same day.
No additional information was provided before inspectors left the building.
What the record does not show is how many other residents the wound nurse treated during those 47 days, or whether she moved between rooms without changing protective gear she was never wearing in the first place. The inspection covered eight residents in the survey sample. The failure was documented for one.
Multidrug-resistant organisms spread in nursing homes through precisely this kind of contact: a caregiver who handles a wound or a catheter without a gown and gloves, then provides care to the next resident on their rounds. Residents in long-term care facilities are often elderly, medically fragile, and less able to fight off infections that a healthier person might clear on their own. An infection that is difficult to treat with standard antibiotics in any patient becomes more dangerous still in that population.
The wound nurse, the director of nursing, the regional director of clinical operations, and the administrator all worked in the same building where this was happening. The facility had a policy that required exactly what was not being done. Forty-seven days passed before a federal inspector walked in and watched.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenburnie Rehab & Nursing Center from 2025-10-29 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 23, 2026 · Our methodology
GLENBURNIE REHAB & NURSING CENTER in RICHMOND, VA was cited for violations during a health inspection on October 29, 2025.
The resident had chronic wounds and a Foley catheter, a tube inserted into the urethra to drain urine from the bladder.
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.