The nursing assistant, identified as CNA BB, admitted during a December 30 interview that she failed to change gloves between cleaning the resident's bowel movement and applying ointment to their skin. Federal inspectors documented the violation during a complaint investigation at PruittHealth - Laurel Park.
"This could transfer bacteria from one area to another and cause infections for residents," CNA BB told inspectors when confronted about her actions.
The facility's own policies required proper hand hygiene procedures. Records showed CNA BB completed annual competency training on hand hygiene just months earlier, on August 1, 2025. The training covered both soap and water techniques and alcohol-based hand sanitizers containing 60 to 95 percent alcohol.
Staff throughout the facility understood the infection risks. LPN CC explained to inspectors that during incontinence care, gloves should be removed after cleaning bowel movements, hands should be sanitized, and new gloves should be put on before continuing care.
"If this was not done, the residents could get infections," the licensed practical nurse said during her December 30 interview.
The Assistant Director of Nursing reinforced the same protocols when interviewed minutes later. She told inspectors that gloves must be changed "when leaving a dirty area for a clean area and after cleaning a bowel movement."
Like the LPN, the nursing supervisor emphasized the health consequences of improper technique.
"The residents could get infections if this was not done," the Assistant Director of Nursing stated.
The violation occurred during routine incontinence care for the resident, identified in inspection documents as R5. After cleaning the resident's bowel movement, CNA BB should have removed her contaminated gloves, sanitized her hands, and put on fresh gloves before applying the barrier ointment to prevent skin breakdown.
Instead, she used the same gloves that had been contaminated during bowel movement cleanup to handle the ointment and touch the resident's perineum. This created a direct pathway for fecal bacteria to spread to the resident's genital area, potentially causing urinary tract infections, skin infections, or other serious complications.
The nursing assistant's admission revealed she understood the risks her actions posed. When inspectors asked about her technique, she acknowledged that using contaminated gloves could transfer harmful bacteria from one body area to another.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the incident highlighted broader concerns about infection control compliance at the facility, particularly given that the nursing assistant had recently completed required training on proper hand hygiene techniques.
The violation occurred under Medicare's infection prevention and control standards, which require nursing homes to establish and maintain comprehensive programs to prevent the spread of infectious diseases. Proper glove use during resident care represents a fundamental component of these infection control measures.
For vulnerable nursing home residents, who often have compromised immune systems and multiple health conditions, even basic infection control failures can lead to serious complications. Urinary tract infections, skin infections, and other complications from poor hygiene practices can result in hospitalizations, prolonged antibiotic treatments, and in severe cases, life-threatening sepsis.
The inspection report documented that multiple staff members, from nursing assistants to supervisory personnel, clearly understood the proper procedures for glove changes during incontinence care. The Assistant Director of Nursing and LPN both articulated the correct protocols and acknowledged the infection risks when proper techniques are not followed.
CNA BB's admission that she knowingly used contaminated gloves despite understanding the risks to residents raised questions about supervision and accountability for infection control practices at the facility.
The December 30 complaint investigation did not specify what prompted the federal review or whether other similar violations occurred at PruittHealth - Laurel Park.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pruitthealth - Laurel Park, LLC from 2025-12-30 including all violations, facility responses, and corrective action plans.