Accel At Crystal Park: Infection Control Failures - OK
The resident, identified in inspection records only as Resident #1, had been placed on enhanced barrier precautions since April — a designation that required any staff member doing wound care to wear both a gown and gloves. The nurse wore no gown. She changed gloves without performing hand hygiene before or after any glove change, and she left the room without washing her hands when she was done.
Inspectors watched the entire procedure on May 26.
The resident carried a serious set of diagnoses: atrial fibrillation, aphasia following a stroke, and an unstageable pressure ulcer on the sacral region — the kind of wound that, by definition, has already broken through the outer layers of skin. The leg wound being treated that morning required a physician-ordered antibiotic cream, gentamicin sulfate, applied daily. A separate order called for Santyl ointment. The nurse applied both, along with a calcium alginate dressing, using a tongue depressor and moistened gauze.
She changed her gloves before cleaning the wound. She changed them again before placing the final dressing. Neither time did she wash or sanitize her hands first.
Fifteen minutes after the procedure ended, an inspector spoke with the nurse. She said she had heard of enhanced barrier precautions but did not know which residents in the facility required them. She said she had received no training on the precautions. As for hand hygiene, she said she washed her hands when they were visibly soiled, and at the end of wound care.
She had not washed them at the end of wound care.
The facility's own hand hygiene policy, on file since 2018, listed the specific moments when hand hygiene was required: before resident contact, before any medical procedure, after contact with wounds or body fluids, after removing gloves. The enhanced barrier precautions policy, updated in April 2024, was equally direct. It required gown and gloves for any wound care involving a skin opening that needed a dressing. It identified wound care specifically as a "high contact resident care activity" — one that creates opportunities for drug-resistant organisms to transfer from a resident to a staff member's hands and clothing, and from there to the next room, the next resident, the next wound.
The facility had 19 residents with wounds at the time of the inspection. Twenty-one residents were on enhanced barrier precautions.
The Director of Nursing, interviewed the following day, confirmed what the policy required and what the nurse had failed to do. Staff were supposed to wear a gown during wound care for any resident with a wound, a peg tube, or a catheter. Hand hygiene was supposed to happen before putting on gloves and with every glove change. The DON said residents on enhanced barrier precautions were identified by a colored name badge on their door.
The nurse had said she did not know which residents were on those precautions.
The DON did not dispute that the nurse should have worn a gown. She did not dispute the hand hygiene lapses. She confirmed them.
Enhanced barrier precautions exist specifically because of multidrug-resistant organisms, the bacteria that have evolved to survive the antibiotics most commonly used against them. Facilities place residents on these precautions when the risk of spreading such organisms is elevated. The precautions are not a formality. They are the mechanism by which a resistant infection stays in one room instead of moving through a building on a nurse's sleeve or under a fingernail.
Resident #1 was already receiving a topical antibiotic. The wound on their leg was open. The sacral ulcer was unstageable. The precautions had been in place for nearly two months.
None of it stopped the nurse from walking in without a gown, changing gloves without clean hands, and walking back out the same way.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accel At Crystal Park from 2026-05-28 including all violations, facility responses, and corrective action plans.
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: August 11, 2026 · Our methodology
Accel At Crystal Park in Oklahoma City, OK was cited for violations during a health inspection on May 28, 2026.
She changed gloves without performing hand hygiene before or after any glove change, and she left the room without washing her hands when she was done.
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.