The infection control violation occurred during morning wound care on November 26 at Harrison Pavilion Care Center. Federal inspectors observed Licensed Practical Nurse #23 and Certified Nursing Assistant #13 treating a resident's right buttocks wound at 10:05 A.M.
LPN #23 removed the old dressing from the resident's sacral pressure ulcer while wearing gloves. She then continued the entire procedure — cleaning the wound with normal saline, applying skin prep to the surrounding area, and placing a new border foam dressing — without ever removing the contaminated gloves or performing hand hygiene.
The resident, identified as Resident #09, had been admitted to the facility on October 20 with multiple serious conditions including cellulitis, the stage three pressure ulcer, atrial fibrillation, and right-side paralysis. A cognitive assessment revealed severe impairment, and the resident required complete assistance with toileting, bathing, dressing, and transfers.
Doctor's orders from November 20 specified that the resident's right buttocks wound should be cleansed with normal saline, treated with skin prep around the wound edges, and covered with border foam dressing once daily.
When interviewed 21 minutes after the observed violation, LPN #23 acknowledged her error. She verified that she had not removed her soiled gloves after taking off the old dressing and confirmed she should have removed the contaminated gloves and performed hand hygiene before cleaning and applying the new dressing.
The facility's own wound care policy, last revised in October 2010, explicitly requires proper infection control procedures. The policy states that staff should "wash and dry hands thoroughly and put on gloves" before beginning wound care. After removing the old dressing, the policy requires staff to "pull gloves over the dressing and discard into appropriate receptacle," then "wash and dry hands thoroughly" before "put on gloves and continue treatment."
This step-by-step protocol exists specifically to prevent cross-contamination between the removal of soiled dressings and the application of clean ones. For residents with pressure ulcers, which are open wounds vulnerable to infection, proper sterile technique is critical to prevent complications that could delay healing or cause serious systemic infections.
Stage three pressure ulcers extend through the full thickness of skin and into underlying tissue. They represent serious wounds that can become life-threatening if infected. Residents with cognitive impairment and limited mobility, like Resident #09, face heightened infection risks because they cannot advocate for themselves or recognize early signs of complications.
The violation occurred despite clear facility policies and basic nursing education that emphasizes infection control as a fundamental patient safety measure. Hand hygiene and glove changes between contaminated and clean procedures represent basic nursing practices taught in entry-level programs.
Harrison Pavilion Care Center houses 78 residents. While inspectors found this infection control failure affected only one of three residents whose wound care they reviewed, the violation demonstrates a breakdown in fundamental nursing protocols designed to protect vulnerable patients from preventable infections.
The Centers for Medicare & Medicaid Services classified the violation as causing minimal harm or potential for actual harm. However, for residents like #09 — who already suffered from cellulitis and an open wound — exposure to contaminated gloves during wound care could have led to serious complications including delayed healing, expanded infection, or sepsis.
Federal inspectors documented the violation during a complaint investigation at the facility. The specific nature of the complaint that triggered the inspection was not detailed in the public report.
Resident #09 remains dependent on facility staff for all aspects of daily care, including the wound treatment that was performed improperly. The resident's severe cognitive impairment, evidenced by the lowest possible score on the mental status assessment, means they cannot communicate concerns about their care or advocate for proper treatment protocols.
The facility's failure to ensure its nursing staff followed established infection control procedures during wound care represents a basic breakdown in patient safety oversight. For residents with serious wounds and compromised immune systems, such violations can mean the difference between healing and life-threatening complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harrison Pavilion Care Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
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