Luxe Rehabilitation and Care Center: Infection Control Failure - OH
The patient, identified in inspection records as Resident 58, had a tracheostomy, meaning a surgically created opening in his throat connected to a breathing tube. He was also on Enhanced Barrier Precautions, a protocol the facility had adopted specifically to prevent the spread of multi-drug resistant organisms. Patients on that protocol require staff to wear both a gown and gloves for high-contact care. The nurse, identified as RN 194, wore only gloves.
When she left the room to find the correct size inner cannula, the piece that fits inside the tracheostomy tube, she had already removed those gloves. She did not wash her hands before touching surfaces in the hallway.
On December 30, inspectors interviewed her directly. She confirmed she had skipped hand hygiene after glove removal. She acknowledged that taking off gloves does not make her hands clean. She acknowledged that because Resident 58 was on Enhanced Barrier Precautions, she should have been wearing a gown as well. She said both things plainly.
The split gauze dressing she had been handling sits directly around the tracheostomy site, one of the most vulnerable points of entry for infection on a human body. A tracheostomy bypasses the nose and mouth, which filter and warm air. Bacteria introduced near that opening have a direct path inward.
The facility's own infection control policies, reviewed by inspectors, were unambiguous. A hand hygiene policy dated October 2024 stated that hand hygiene is the primary means of preventing healthcare-associated infections and that washing must occur after removing gloves, not instead of it. The policy said gloves and hand hygiene work together. One does not substitute for the other.
The Enhanced Barrier Precautions policy, dated July 2024, identified exactly the kind of patient Resident 58 was. Patients with indwelling medical devices or chronic wounds were listed as requiring the protocol. A tracheostomy is an indwelling medical device. The policy required gown and gloves for high-contact care activities. RN 194 wore neither a gown nor, by the time she left the room, gloves.
A second nurse, LPN 170, was present and waiting on the inner cannula RN 194 went to retrieve. The inspection record does not indicate whether LPN 170 raised a concern about the missing PPE or the absent hand hygiene.
Inspectors classified the violation as representing minimal harm or potential for actual harm, affecting few residents. It was documented as an incidental finding tied to a broader complaint, number 2684375, that brought investigators to the facility in the first place. The inspection report does not describe what that original complaint alleged.
The gap between the facility's written policies and what happened in Resident 58's room on that afternoon was not a matter of missing rules or unclear guidance. The policies existed. They were specific. They named the exact situation, a patient with an indwelling device, and the exact requirement, gown and gloves, hand hygiene always. The nurse who violated them understood them well enough to explain, when asked, precisely what she had done wrong.
Resident 58 remained at the facility with his tracheostomy and his elevated infection risk. The inspection record does not say whether he developed an infection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Luxe Rehabilitation and Care Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
LUXE REHABILITATION AND CARE CENTER in LANCASTER, OH was cited for violations during a health inspection on December 31, 2025.
He was also on Enhanced Barrier Precautions, a protocol the facility had adopted specifically to prevent the spread of multi-drug resistant organisms.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.