Federal inspectors observed CNA D providing incontinence care to Resident #5 on September 30. The resident was "heavily soaked in urine" when the aide unfastened her brief. He cleaned only her abdominal folds and buttocks, skipping the perineal area entirely.
After handling the soiled linens, CNA D used the same gloves to put on a clean brief. He never changed gloves or washed his hands during the procedure.
Fifteen minutes later, inspectors watched the same aide provide care to Resident #6. This resident was also heavily soaked in urine, with the brief, draw sheet and mattress cover all saturated. The resident had a bowel movement during the cleaning.
Again, CNA D failed to clean the perineal area. He positioned the resident on her side, cleaned the buttocks, then used the same contaminated gloves to handle clean linens and a fresh brief.
When inspectors interviewed CNA D immediately after the second incident, he acknowledged multiple failures. "He forgot to perform hand hygiene during perineal care," according to the inspection report. The aide said he knew he was supposed to wash hands between care procedures when gloves became contaminated, "but he forgot."
CNA D admitted he should have cleaned the perineal area before turning both residents and after changing soiled briefs and linens. "But he forgot it escaped his mind," inspectors wrote.
The aide understood the consequences of his lapses. He told inspectors that failure to wash hands between care and when gloves were contaminated "could lead to cross contamination." He said skipping perineal care on both residents "could predispose them to infection."
LVN C witnessed the care provided to Resident #6 and confirmed the violations to inspectors. She stated CNA D failed to change gloves and wash hands after they became soiled. She also confirmed he failed to clean the perineal area before turning the resident.
The licensed vocational nurse explained the medical risks. "The risk of not cleaning the peri area and changing gloves and perform hand hygiene could lead to skin irritation and urinary tract infections," she told inspectors.
Nursing leadership acknowledged the facility's infection control standards were clear. The Assistant Director of Nursing told inspectors her expectation during incontinence care was for staff to complete hand hygiene before resident contact, during care, and after care. Staff must also perform perineal care before applying a clean brief.
The ADON said CNA D should have completed hand hygiene and changed gloves while providing care to both residents "to prevent cross contamination and infection." She noted that nursing staff had been offered in-service training on hand hygiene and infection control.
The Director of Nursing echoed these expectations. She told inspectors staff must complete hand hygiene before, during and after care. Between care procedures, hands are "considered dirty after cleaning the resident," requiring hygiene and fresh gloves.
The DON confirmed CNA D should have completed perineal care before applying clean briefs to both residents and before putting clean linens on Resident #6. Hand hygiene was expected "to prevent the spread of infection," and nursing staff had received training on the topic.
Facility training records showed hand washing instruction dated August 29, 2025, just one month before the violations. The facility's Hand Hygiene for Staff and Residents policy, dated July 2024, specifically required hand hygiene "before resident contact" and "after contact with soiled or contaminated articles, such as articles that are contaminated with body fluids."
The policy also mandated hygiene after resident contact and "after toileting or assisting others with toileting."
Despite recent training and clear written policies, CNA D's care of two heavily soiled residents violated multiple infection control standards. His use of contaminated gloves on clean supplies created the exact cross-contamination risks that proper hand hygiene is designed to prevent.
Both residents remained vulnerable to the urinary tract infections and skin irritation that medical staff warned could result from the aide's admitted lapses in basic care protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Williamsburg Village Healthcare Campus from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
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