The December 29 incident at Hillcrest Health & Rehab involved a patient with a pressure ulcer on the left foot. Federal inspectors watched as RN-N entered the room without a protective gown, despite facility requirements, and began wound care on the resident's left medial metatarsal pressure ulcer.
During the procedure, RN-N removed her right-hand glove and held the dressing against the wound with her ungloved right hand while taping it in place. She then walked down the Ivy Court hallway to the nurse's station.
The same resident received wound care earlier that morning from the facility's wound nurse, RN-F, who also violated infection control protocols. At 2:58 AM, RN-F entered the room without a gown to treat the resident's right knee surgical incision.
RN-F knelt on the floor during the procedure, allowing her clothing to make direct contact with the resident's carpeting. After completing the wound care, she walked through multiple areas of the facility — down the Ivy Court hallway to the laundry room on Ivy Lane, then to the main hall, then to the Registered Dietician's office, and finally down another hallway.
The resident should have been placed in Enhanced Barrier Precautions, a protocol requiring staff to wear gowns and gloves during care. No EBP sign was posted outside the room, and no gowns were available for staff use.
When questioned by inspectors, RN-F admitted she was "unsure why Resident 4 was not in EBP." The Assistant Director of Nursing, who also serves as the facility's Infection Preventionist, confirmed the resident should have been under enhanced precautions and that staff should have worn gowns and gloves during wound care.
The infection control failures extended beyond individual nursing practices. Inspectors found six recliners in the facility's common area with vinyl that had peeled away from the armrests and seats, making them impossible to properly clean and disinfect.
The chairs were positioned around a television in the commons area where residents gather. The Environmental Services Director confirmed the furniture was missing vinyl and could not be adequately cleaned.
Enhanced Barrier Precautions are designed to prevent the spread of multidrug-resistant organisms and other infections in nursing homes. The protocol requires healthcare workers to wear disposable gowns and gloves during all resident contact, not just wound care procedures.
The violations occurred during a complaint investigation at the 120-bed facility. Inspectors classified the harm level as minimal, though the practices created potential for actual harm to residents.
Wound care procedures require strict adherence to infection control protocols because open wounds provide direct pathways for bacteria and other pathogens to enter the bloodstream. Removing gloves during procedures and touching wounds with bare hands can introduce new infections or spread existing ones to other parts of the body.
The contaminated clothing worn by RN-F as she moved through the facility could have spread infectious material to laundry areas, dietary offices, and hallways used by other residents and staff.
Federal nursing home regulations require facilities to establish and maintain infection prevention and control programs. Staff must use standard precautions with all residents and implement additional protective measures when residents have confirmed or suspected infections.
The December 30 inspection report did not indicate whether the facility had implemented corrective measures or whether the resident experienced any adverse health effects from the improper wound care procedures.
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.