Mi Casita Nursing: Hand Hygiene Failure During Wound Care - TX
The man in the room, identified in inspection records only as Resident 32, is in his seventies. He was admitted to Mi Casita Nursing and Rehabilitation Center on Quaker Avenue with three serious conditions: chronic obstructive pulmonary disease, a stage 3 pressure ulcer on his right heel, and peripheral vascular disease, a circulatory problem that limits blood flow to the extremities and slows wound healing. His cognition was moderately impaired, according to a standardized assessment completed in January. He could not easily advocate for himself or notice what the nurse did or did not do before touching him.
What she did not do was wash her hands.
State surveyors were watching on the morning of March 26 when LVN B, as she is identified in the inspection report, rolled her wound care cart to the room, gathered her supplies on a tray, and walked in. She set the supplies down. She put on a clean gown. She put on clean gloves. She began unwrapping the wound on Resident 32's right heel, a stage 3 ulcer, meaning it had already broken through the skin and into the tissue beneath.
She had not washed her hands after entering the room.
Ten minutes later, a surveyor interviewed her about it. LVN B said she knew she was supposed to wash her hands before providing care. She said she had been trained on infection control a few months ago. She said she had washed her hands at the sink before the surveyor started watching, and that after she entered the room, it had slipped her mind.
Then she said something that cut to the center of the problem. A potential negative outcome for the residents, she told the surveyor, was an increased risk for infection.
She knew. She had been trained. She had signed the training document. And she walked past the sink anyway.
A stage 3 pressure ulcer is not a surface wound. It has reached the subcutaneous tissue, the layer beneath the skin, and it is open. For a man with peripheral vascular disease, the blood that normally fights infection and carries healing oxygen to damaged tissue is already arriving slowly. His lungs, compromised by COPD, are less efficient at moving oxygen through his body in the first place. The wound on his heel was being treated every day shift with a specific protocol: cleanse, pat dry, apply iodosorb and calcium alginate, cover and secure with bordered gauze. That order had been in place since January 9.
Every one of those daily treatments was an opportunity for contamination. Gloves do not replace handwashing. Whatever bacteria LVN B had picked up touching the wound care cart, the door handle, the supply tray, any surface between the hallway and the bedside, was still on her hands when she pulled those gloves on.
The director of nursing was interviewed the following morning. She said she expected staff to wash their hands before starting any care. She said she did not know why LVN B had not done so after entering the room. She confirmed that LVN B had received infection control training in February 2026, the same training whose sign-in sheet bore LVN B's signature dated February 16.
The administrator was interviewed that same afternoon. She said she expected staff to wash their hands before providing care. She said the director of nursing manages infection control concerns at the facility. She said she knew LVN B had been trained, but the director of nursing would have the details.
Nobody offered an explanation for what happened between the training and the wound care cart.
The facility's own hand hygiene policy, last revised in October 2023, states that hand hygiene is the primary means to prevent the spread of healthcare-associated infections, that all personnel are expected to adhere to hand hygiene practices, and that hand hygiene is required immediately before touching a resident. The policy also states, specifically, that wearing gloves does not replace handwashing.
Inspectors rated the violation at the level of minimal harm or potential for actual harm, one of the lower tiers in the federal deficiency framework. The citation covers one resident out of four reviewed for infection control during the survey, which was completed March 27.
The inspection report does not say whether Resident 32 developed an infection. It does not say whether anyone reviewed the other daily wound care treatments he received before March 26 to determine whether the same step had been skipped before. It does not say whether the facility's infection control logs showed any prior concerns about LVN B's technique.
What it says is that a man with an open wound, compromised circulation, and damaged lungs was being treated by a nurse who walked past the sink, and that when she was asked about it afterward, she said it had slipped her mind.
Resident 32's wound care order runs through every day shift. The treatment continues.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mi Casita Nursing and Rehabilitation Center from 2026-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
MI CASITA NURSING AND REHABILITATION CENTER in LUBBOCK, TX was cited for violations during a health inspection on March 27, 2026.
The man in the room, identified in inspection records only as Resident 32, is in his seventies.
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.