Federal inspectors witnessed the December 17 incident at Shady Grove Nursing and Rehabilitation Center during a complaint investigation. The nursing assistant had "double gloved" — wearing two sets of gloves on both hands — but never changed either layer while moving from one body area to another during intimate care.
The assistant rolled the resident onto their right side and used a wet washcloth to clean multiple areas of the body, spreading potential contamination across the person's skin. Inspectors documented the violation as part of infection control failures at the Rockville facility.
Unit Manager 23 acknowledged the problems during questioning the same day. "The expectation with perineal care is that the staff use hand sanitizer," the manager told inspectors at 1:50 pm. "When doing catheter care they should use a wash cloth and water, and should wash their hands and change gloves."
The manager admitted staff had been improperly double-gloving and promised education. "They are not to use double gloves, that they will educate staff," the manager said. For female residents, "staff should only wipe in one direction, and that they will definitely do some education on that topic."
Another unit manager, identified as UM 17, confirmed the facility's glove protocols were being ignored. "Staff should not bring two gloves and should use one set of gloves at a time," the manager stated during a December 17 interview at 2:25 pm.
The nursing assistant involved, identified as GNA 21, had worked at Shady Grove for two years. When questioned December 19, the assistant revealed a fundamental misunderstanding of infection control. "The reason they doubled gloved was because they thought they were protecting the resident and themselves, but he had learned now not to do that," according to the inspection report.
GNA 21 described infection control as "how to wash your hands, how to take care of the residents and how to protect yourself and the resident." Yet the assistant's actions demonstrated the opposite — potentially exposing the vulnerable resident to bacterial contamination by using the same gloves to handle fecal matter and clean other body areas.
Infection Preventionist 25 outlined proper procedures during a December 18 interview. Staff should "do an alcohol rub upon entering and put on gloves. Then wash their hands and in between tasks wash their hands for twenty seconds. They should work front to back, not use the same towel on different body parts, and clean deep in crevices."
The infection control expert said training had occurred recently — "last week during an annual skill check and two weeks ago for the nurses." Despite this recent education, staff continued dangerous practices that could spread infections among residents.
The violations occurred during care of Resident 18, who required protective barriers around non-wound areas. Unit Manager 17 noted that "every area that does not have a wound should have a barrier, because we want to protect that area." The contaminated glove incident directly contradicted this protective approach.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the incident revealed systemic problems with basic infection control training and supervision at the facility.
The nursing assistant's confusion about double-gloving highlighted gaps in staff education. Rather than providing extra protection, the practice created a false sense of security while staff continued unsafe cleaning techniques that could transmit dangerous bacteria between body areas and potentially to other residents.
Unit managers acknowledged multiple protocol failures beyond the glove incident. They admitted collection bags were being improperly stored in trash bins and staff weren't following proper front-to-back wiping techniques for female residents.
The December 19 complaint investigation exposed fundamental breakdowns in infection prevention at a time when nursing homes face intense scrutiny over resident safety. The contaminated glove incident represented exactly the type of basic care failure that can lead to serious infections among elderly residents with compromised immune systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shady Grove Nursing and Rehabilitation Center from 2025-12-19 including all violations, facility responses, and corrective action plans.