The violations occurred during wound care for Resident #15, a man with Alzheimer's dementia who required Enhanced Barrier Precautions due to his risk of carrying multidrug-resistant organisms. Federal inspectors observed the November 25 treatment session that exposed both the vulnerable resident and the broader facility to potential infection.
Resident #15 had been placed under the special precautions because of his severe medical conditions, including hemiparesis, peripheral vascular disease, and the stage IV pressure ulcer on his left heel. Stage IV ulcers represent the most serious category of pressure wounds, with tissue loss so extensive that muscle, tendon, ligament, or bone becomes visible.
During the 1:21 p.m. wound care session, Licensed Practical Nurse #174 made multiple critical errors. After removing the resident's soiled dressing and disposing of contaminated gloves, she failed to wash her hands before putting on new gloves. She then left the resident's room while still wearing her isolation gown to retrieve wound cleanser from another location.
The nurse returned to continue treatment while wearing the same potentially contaminated protective equipment she had worn outside the isolation room.
More violations followed. LPN #174 cleansed the wound with gauze and cleanser, disposing of each piece of gauze after use, then removed her soiled gloves and immediately applied fresh gloves without performing any hand hygiene. She applied Santyl medication to new gauze, placed it on the resident's heel, wrapped the dressing, and secured it with tape.
Then she left the room again, still wearing the same gown and gloves.
When LPN #174 returned a second time in the contaminated protective equipment, she used a black marker to initial and date the dressing before finally exiting.
The facility's Director of Nursing had made clear expectations that morning. During a 9:21 a.m. interview, she told inspectors that staff were expected to bring all necessary supplies into the room before beginning care and to follow proper infection control techniques during wound care.
When confronted about her actions at 1:47 p.m., LPN #174 acknowledged her mistakes. She verified that she should have removed her gown and gloves before leaving the resident's room. She also confirmed she should have performed hand hygiene after removing soiled gloves and before applying new ones.
The facility's own policies, reviewed by inspectors, spelled out the exact steps LPN #174 had ignored. The Aseptic Dressing Change policy from January 2024 required staff to wash hands after placing soiled dressings in trash, apply clean gloves before cleansing wounds, discard cleansing supplies, wash hands again, apply new gloves, then apply medication and clean dressing.
The Enhanced Barrier Precautions policy from March 2024 specifically addressed residents with wounds, requiring proper application and removal of gloves and gowns during high-contact care activities like wound treatment.
During a December 1 follow-up interview, the Director of Nursing confirmed these were standard nursing practices. Staff should remove gowns before exiting resident rooms, apply clean gowns before re-entering, wash hands before starting wound care, wash hands every time gloves are removed, wash hands before applying clean dressings, and wash hands after completing treatment.
The DON emphasized that staff were expected to follow all infection control policies and procedures.
Resident #15's cognitive impairment from Alzheimer's dementia left him entirely dependent on staff for activities of daily living, according to his care assessment. His guardian made medical decisions for him. The severe pressure ulcer on his left heel required ongoing specialized wound care that the facility's staff had failed to provide safely.
The infection control violations occurred despite the facility's 77-resident census providing ample opportunity to properly staff and supply the wound care procedure.
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.