The November 25 incident at Woods Edge Rehab and Nursing involved a patient with Alzheimer's disease who required enhanced barrier precautions to prevent transmission of drug-resistant infections. The resident had a stage IV pressure ulcer on his left heel — a severe, full-thickness wound exposing muscle, tendon, or bone.
Licensed Practical Nurse 174 removed the patient's soiled dressing and threw it in the trash along with her contaminated gloves. She then applied new gloves without washing her hands.
When another nurse asked where the wound cleanser was, LPN 174 left the room still wearing her isolation gown. She returned with the cleaner, still in the same contaminated protective equipment that should have been removed before exiting.
The nurse then cleaned the wound with gauze, threw away each piece of soiled gauze, removed her gloves, and put on fresh ones. She never washed her hands.
She applied Santyl medication to new gauze, placed it on the patient's heel, wrapped the dressing, and taped it in place. Then she left the room again, still wearing the same gown and gloves.
LPN 174 returned one more time in the same contaminated protective equipment to initial and date the dressing with a black marker.
The patient required a guardian for his care decisions. His medical record showed hemiplegia, peripheral vascular disease, and hypertension in addition to his Alzheimer's diagnosis. He depended completely on staff for daily activities.
When interviewed 26 minutes after the wound care, LPN 174 acknowledged she should have removed her gown and gloves before leaving the patient's room. She also confirmed she should have washed her hands after removing the soiled gloves and before applying new ones.
The Director of Nursing told inspectors that morning that staff were expected to bring all supplies into the room before starting care and follow proper infection control techniques during wound care.
A week later, the nursing director verified it was standard practice to remove gowns before exiting a resident's room and apply clean gowns before re-entering. She said staff should wash hands before starting wound care, anytime they remove gloves, after touching anything soiled, before applying clean dressings, and after completing treatment.
The facility's own policy for aseptic dressing changes, dated January 2024, requires washing hands after placing soiled dressings in trash, applying clean gloves to cleanse wounds, washing hands again before applying medication and clean dressings, and removing gloves before taping dressings in place.
Woods Edge's enhanced barrier precautions policy from March requires proper application and removal of gloves and gowns during wound care for any resident with wounds, regardless of whether they're colonized with drug-resistant organisms.
Enhanced barrier precautions are designed specifically to reduce transmission of multidrug-resistant organisms in nursing homes during high-contact care activities like wound treatment.
The 77-bed facility failed to follow these infection control measures for a cognitively impaired resident who couldn't advocate for himself. The patient's stage IV pressure ulcer represented one of the most severe wound classifications, making proper sterile technique critical to prevent further complications.
Federal inspectors found the violation created minimal harm or potential for actual harm, but noted it affected infection control protocols designed to protect vulnerable residents from dangerous drug-resistant infections that have become increasingly common in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woods Edge Rehab and Nursing from 2025-12-01 including all violations, facility responses, and corrective action plans.