The violations put residents at risk for bacterial infections and cross-contamination between patients, according to the inspection report. Staff failed to follow the facility's own wound care procedures and Centers for Disease Control guidelines for preventing the spread of germs in healthcare settings.
Inspectors documented multiple breaches of infection control standards during wound treatment observations. Staff contaminated sterile supplies by placing them on unsanitized surfaces and failed to perform proper hand hygiene between different stages of wound care.
The facility's Director of Nursing, who also serves as the infection preventionist, told inspectors that proper wound care required a specific sequence: enter the resident's room, wash hands, sanitize surfaces used for supplies, set up materials, perform hand hygiene again, apply gloves, remove old dressings, remove gloves, sanitize hands, apply new gloves, clean the wound, apply treatment, remove gloves, and wash hands before leaving.
She emphasized that staff should wash their hands for at least 30 seconds — "or Happy Birthday twice" — to kill bacteria and microbes that might be present. Hand hygiene was required any time staff had contact with residents, before putting on gloves, after removing gloves, and before leaving resident rooms.
The Director of Nursing said she expected staff to remove personal protective equipment and put on clean gear between residents to prevent cross-contamination. Used gowns should never be placed on surfaces once removed because they were contaminated, she explained.
"It was everyone's responsibility to ensure infection control practices were followed to prevent infection," she told inspectors. As the facility's infection preventionist, she said she was responsible for ensuring staff followed infection control policies and that nurses provided care according to professional standards.
The facility's own wound care validation checklist from 2022 specified that staff should clean bedside tables as needed, maintain supplies as sterile or clean as indicated while avoiding contamination, cleanse wounds thoroughly without contaminating other skin surfaces, and discard disposable items and gloves in appropriate containers.
The facility's wound care policy, updated in March 2024, listed situations requiring hand hygiene including before and after changing dressings, upon contact with a resident's intact skin, and after removing gloves. The policy recommended washing hands with soap and water by "rubbing hands together vigorously for at least 20 seconds."
Federal health officials have long emphasized the critical importance of proper hand hygiene in healthcare settings. CDC guidelines state that germs can spread from person to person or from surfaces to people when healthcare workers touch contaminated surfaces or objects.
The CDC identifies key times for hand washing, including before and after treating cuts or wounds, and recommends scrubbing hands for at least 20 seconds. When soap and water aren't available, alcohol-based hand sanitizer can be used as an alternative.
Personal protective equipment protocols are equally stringent. CDC infection control guidelines specify that gowns should be removed and hand hygiene performed before leaving a patient's environment. The same gown should never be worn between patients, and gowns should not be worn in hallways or corridors as pathogens can transfer from one patient to another.
The inspection found that staff at Normandy Terrace failed to follow these basic infection control measures during wound care procedures. The violations represented a breakdown in fundamental healthcare safety practices designed to protect vulnerable nursing home residents from preventable infections.
Nursing home residents are particularly susceptible to healthcare-associated infections due to advanced age, underlying medical conditions, and compromised immune systems. Proper infection control becomes even more critical in facilities where residents live in close quarters and receive frequent hands-on care.
The facility's own policies aligned with federal standards, acknowledging the importance of preventing cross-contamination and maintaining sterile conditions during wound treatment. However, the gap between written procedures and actual practice put residents at unnecessary risk for bacterial infections that could complicate existing medical conditions.
The inspection classified the violations as having minimal harm or potential for actual harm, affecting some residents at the facility. Federal inspectors documented the infection control failures as part of a complaint investigation conducted in November 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Normandy Terrace Nursing & Rehabilitation Center from 2025-11-25 including all violations, facility responses, and corrective action plans.
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