El Dorado Care: Infection Control Violations - KS

Federal inspectors observed Consultant Staff KK clean an open wound on Resident 8's right great toe, then continue wearing those same soiled gloves while opening and closing drawers on the treatment cart. She handed clean dressings to her colleague while still wearing the contaminated gloves, then entered the resident's closet to retrieve more supplies without changing her protective equipment.

The violations extended beyond a single treatment. Consultant Staff JJ removed her gloves mid-procedure to take a photograph of the resident's foot with her personal phone, then put the phone back in her pocket and applied new gloves without washing her hands first.

After completing the wound care, Consultant Staff KK used the same soiled gloves she had worn throughout the entire procedure to wipe down the treatment cart with a sanitization wipe. Only then did both staff members remove their protective equipment and perform hand hygiene.

When confronted by inspectors the following day, both staff members acknowledged their failures. Consultant Staff JJ admitted she should have removed both gloves and performed hand hygiene before handling her phone. Consultant Staff KK confirmed she had kept the same gloves on while touching dressing supplies, the cart, and door handles.

"I thought I used a different 4x4 when I cleansed the wound," Consultant Staff KK told inspectors, but confirmed she had left her gloves on the entire time. She acknowledged she should have removed her gloves after cleaning the wound and washed her hands before continuing.

The infection control breakdowns weren't isolated to one resident's care.

Inspectors observed four wound care team members treating Resident 2, who was classified as requiring Enhanced Barrier Precautions due to multiple medical devices. The resident had a colostomy, urinary catheter, and dialysis port in his left chest. None of the consultant staff wore the required protective gowns during the wound care procedure.

They wore only gloves.

Certified Medication Aide R explained that Resident 2's medical conditions required staff to wear both gowns and gloves when providing direct care. The Enhanced Barrier Precautions designation exists specifically for residents like him, who face elevated infection risks due to indwelling medical devices.

Consultant Staff II, who was present during the treatment, confirmed to inspectors that none of the wound care team had worn the required gowns that morning. She acknowledged they should have used the complete personal protective equipment protocol for residents on Enhanced Barrier Precautions.

Administrative Nurse E, who serves as the facility's Infection Preventionist, told inspectors she expected wound care staff to use both gowns and gloves for residents requiring Enhanced Barrier Precautions. She also expected all staff to perform hand hygiene when removing gloves and to avoid touching clean items or other residents with soiled gloves.

"I expected all wounds to be cleansed by standards of care," Administrative Nurse E said.

The facility's own policies, updated as recently as October 2025, explicitly require these infection control measures. The Enhanced Barrier Precautions policy, dated April 2025, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms.

These organisms pose particular risks to residents with wounds and indwelling medical devices, who face elevated chances of both acquiring and harboring dangerous bacteria. The policy specifically notes that these resistant organisms can transfer indirectly from resident to resident during high-contact care activities.

The facility's hand hygiene policy identifies handwashing as "the primary means to prevent the spread of infections." It requires employees to wash their hands for at least twenty seconds before and after direct resident contact, after removing gloves, and before handling clean or soiled dressings and gauze pads.

The violations affected multiple residents and occurred during routine wound care procedures that happen daily throughout the facility. Federal inspectors classified the deficiency as having caused minimal harm or potential for actual harm, but affecting many residents.

The contaminated glove incident with Resident 8 demonstrated a cascade of infection control failures during a single treatment session. Staff wore soiled protective equipment while handling clean medical supplies, contaminated treatment equipment with unwashed hands, and failed to follow basic hygiene protocols between different phases of wound care.

The Enhanced Barrier Precautions violations with Resident 2 revealed systematic failures to protect the facility's most vulnerable residents. These residents require additional protective measures precisely because their medical conditions make them more susceptible to dangerous infections.

Both incidents occurred during routine wound care procedures conducted by consultant staff who acknowledged they understood the correct protocols. The failures weren't due to lack of knowledge or unclear policies, but to staff simply not following established infection control standards during patient care.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for El Dorado Care and Rehab from 2026-04-09 including all violations, facility responses, and corrective action plans.

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