The contamination occurred when CNAs C and D provided perineal care to a resident. After CNA C cleaned the resident while wearing gloves, she placed a clean brief under the person and rolled her back without changing gloves or washing hands first. Both staff then repositioned the resident and covered her up while still wearing the soiled gloves used during cleaning.
Only after completing all care did the assistants remove their gloves and gowns and wash their hands.
When inspectors interviewed both CNAs on November 17, they acknowledged the violation. Both stated they were supposed to perform hand hygiene before incontinent care and once they finished. CNA C admitted she should have also performed a glove change and hand hygiene when she finished cleaning the resident, before putting on the clean brief and repositioning her.
They both stated the risk of not performing hand hygiene and glove changes was the spread of germs and infections.
The facility's Director of Nursing confirmed the expectation during an interview the same day. She stated staff must perform hand hygiene before care, after each glove change, and before leaving the room. Staff were also required to change gloves when soiled, before moving to the clean part of care.
The DON announced they would be starting perineal care skills checks immediately as well as hand hygiene training.
Bedford Wellness's own policies explicitly prohibited the contamination that occurred. The facility's hand hygiene policy, reviewed by inspectors, stated that the facility considers hand hygiene "the primary means to prevent the spread of infections." Staff are trained and regularly receive in-service training on preventing healthcare-associated infections.
The policy required hand hygiene immediately upon entering and exiting any resident-occupied area, regardless of glove use. Hand hygiene must always be the final step after removing personal protective equipment. "The use of gloves does not replace hand hygiene procedures," the policy stated.
The facility's perineal care policy, dated June 2020, provided step-by-step instructions that the CNAs failed to follow. After washing the pubic area and turning the resident to their side, staff were required to "Remove gloves. Wash hands or use alcohol-based sanitizer."
The policy included a specific warning: "Do not touch anything with soiled gloves after procedure (i.e. curtain, side rails, clean linen, call bell, etc.)"
Staff were then supposed to put on clean gloves before cleaning and returning equipment and placing soiled linen in proper containers. The final steps required removing gloves and washing hands again.
The CNAs' actions violated multiple steps of this protocol. By keeping soiled gloves on while handling the clean brief, repositioning the resident, and covering them up, they contaminated clean supplies and the resident's environment with materials from the cleaning process.
The violation represented what inspectors classified as "minimal harm or potential for actual harm" affecting few residents. However, infection control breaches during intimate care create particular risks, as they involve direct contact with residents' most vulnerable areas and can spread dangerous pathogens.
Healthcare-associated infections remain a persistent problem in nursing homes, where residents with compromised immune systems live in close quarters. Proper hand hygiene and glove changes serve as critical barriers to transmission.
The complaint investigation revealed that despite having detailed policies and trained staff who understood the requirements, basic infection control protocols were not followed during routine care. The facility's immediate response of implementing skills checks and additional training suggested recognition that the violations could recur without intervention.
The contamination incident at Bedford Wellness illustrated how lapses in fundamental infection control practices can occur even when staff understand the risks and facilities maintain appropriate policies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bedford Wellness & Rehabilitation from 2025-11-17 including all violations, facility responses, and corrective action plans.
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