Federal inspectors observed the violations during wound care procedures at Mesa Vista Inn Health Center in October. The assistant director of nursing, identified as ADON B, completed wound treatment for a resident in their bedroom, then removed the glove from her left hand and used that ungloved hand to grasp the palm area of the glove still on her right hand.
The contamination continued when ADON B removed her gown. Without gloves, she grabbed the front of the contaminated gown instead of pulling it off from the back, which facility policy designated as the clean area.
When confronted by inspectors, ADON B described her glove removal technique as pulling one glove off and tucking her ungloved fingers inside the other glove to remove it. She said she thought this was how she had removed gloves after wound care for two other residents during the inspection.
ADON B acknowledged the importance of proper glove removal. "It was important to remove contaminated gloves as recommended to keep their hands as clean as possible and decrease the risk of contamination/infection," she told inspectors.
She also understood the gown protocol. ADON B said she "was not supposed to touch the front of the gown without gloves and was supposed to pull the contaminated gown from the back when not wearing gloves because the back of the gown was considered clean."
The violations occurred while treating residents who required enhanced barrier precautions, a heightened infection control protocol for patients with wounds or indwelling catheters. These residents face increased vulnerability to infections that could worsen their conditions.
ADON B told inspectors that not removing contaminated gowns correctly "could increase the risk for infection/spread of bodily fluids." She said she and the director of nursing were responsible for ensuring infection control practices were followed by facility staff.
The director of nursing confirmed the proper procedures during her interview with inspectors. When removing personal protective equipment, she explained, "if gloves were worn the gown could be grabbed from the front and pulled off but when gloves were removed before the gown, the gown should be pulled from the back."
For glove removal, the director said the technique "should be done by pinching the first glove and pulling off and then go underneath the second glove and remove." This method reduces contamination and limits exposure to other residents.
The director emphasized that personal protective equipment should be worn "any time hands on care was provided to residents, even when observing a wound." For residents on enhanced barrier precautions, staff must put on protective equipment before entering the room and remove it before leaving.
She explained that enhanced barrier precautions protect residents "from organisms entering open area on the body" and that "not following EBP could worsen infections."
The facility's infection control policy, updated in March 2023, states that gowns and protective equipment are worn "to provide barrier protection and reduce the opportunity for transmission of microorganisms" and "to prevent contamination of clothing and to protect skin of personnel from blood and body fluid exposures."
CDC guidelines referenced in the inspection specify the proper sequence: grasp the palm area of one gloved hand with the other gloved hand and peel off the first glove, hold the removed glove in the gloved hand, then slide fingers of the ungloved hand under the remaining glove at the wrist and peel off the second glove over the first.
For gown removal, the CDC instructs to unfasten ties while ensuring sleeves don't contact the body, then pull the gown away from neck and shoulders, touching only the inside of the gown.
The violations occurred despite ADON B's acknowledgment that she and the director of nursing shared responsibility for ensuring proper infection control practices throughout the facility. The director called infection control "a team effort."
The contamination incidents put vulnerable residents at Mesa Vista Inn at unnecessary risk during routine wound care, the very procedures designed to promote healing rather than spread infection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mesa Vista Inn Health Center from 2025-11-24 including all violations, facility responses, and corrective action plans.