The incident occurred at Hillcrest Health & Rehab on December 29, when federal inspectors observed RN-N performing wound care on Resident 4's left medial metatarsal pressure ulcer. The resident's room lacked the required isolation sign and had no protective gowns available for staff use.
RN-N entered the room without donning a gown and began the wound care procedure. Partway through, she removed her right-hand glove and pressed the dressing directly against the wound with her ungloved hand while securing it with tape. She then walked down the Ivy Court hallway to the nurse's station.
Earlier that morning at 2:58 AM, inspectors witnessed another breach of infection control protocols in the same resident's room. RN-F, identified as the facility's wound nurse, treated Resident 4's right knee surgical incision without wearing a gown. During the procedure, RN-F knelt on the floor, allowing her clothing to make direct contact with the resident's carpet.
After completing the wound care, RN-F traveled through multiple areas of the facility. She walked from the resident's room down the Ivy Court hallway to the laundry room on Ivy Lane, then continued down the main hall to the Registered Dietician's office, which she shared with RN-F, before proceeding down another hallway.
When questioned by inspectors, RN-F admitted uncertainty about why Resident 4 was not placed in Enhanced Barrier Precautions, a protocol designed to prevent the spread of infection through additional protective measures.
The facility's Assistant Director of Nursing, who also serves as the Infection Preventionist, confirmed during a December 29 interview that Resident 4 should have been under Enhanced Barrier Precautions but was not. The administrator acknowledged that staff should have worn both gowns and gloves during wound care procedures.
Beyond the infection control violations, inspectors documented additional cleanliness issues throughout the facility. In the commons area, six recliners positioned around the television had vinyl peeling away from both armrests and seats. The damaged surfaces prevented proper cleaning and disinfection.
The Environmental Services Director confirmed during a December 30 interview that the chairs were missing vinyl covering and could not be adequately cleaned in their current condition.
The violations occurred during a complaint investigation, suggesting concerns serious enough to prompt federal oversight. Enhanced Barrier Precautions typically apply to residents with multidrug-resistant organisms or other conditions requiring additional infection control measures.
The facility's failure to maintain proper isolation protocols while treating open wounds creates risks for both the affected resident and others in the facility. Pressure ulcers and surgical incisions provide direct pathways for bacteria and other pathogens to enter the body.
RN-F's practice of kneeling on carpet during wound care particularly concerned inspectors, as carpeting harbors bacteria and other contaminants that can transfer to clothing and subsequently to other residents during care activities.
The nurse's post-procedure movement through multiple facility areas without changing protective equipment or clothing compounds the infection risk. Her route included the laundry room, administrative offices, and resident hallways.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to some residents. However, the breaches occurred in the facility's most vulnerable care area, where residents with open wounds require the highest level of protection against infection.
The damaged furniture in common areas represents an ongoing infection control challenge, as surfaces that cannot be properly cleaned and disinfected pose continuous risks to residents who use these spaces daily.
Hillcrest Health & Rehab's infection control failures occurred despite having a designated wound nurse and an Infection Preventionist on staff, suggesting systemic issues with protocol implementation rather than lack of expertise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillcrest Health & Rehab from 2025-12-30 including all violations, facility responses, and corrective action plans.