Scenery Hills Rehab: Wound Care Hand Hygiene Failure - PA
The May 29 inspection at Scenery Hills Rehabilitation and Healthcare Center on Lions Health Camp Road found one infection control violation involving a resident identified in records only as Resident 7. The finding was classified as minimal harm or potential for actual harm, affecting few residents. It was the facility's only cited deficiency in the health inspection.
Resident 7 was cognitively impaired and needed help with daily care. The resident had a stage III pressure ulcer on the sacral region, a wound that has eaten through the full thickness of the skin and reached the underlying fatty tissue. A physician's order from May 12 spelled out the treatment: cleanse the area with wound cleanser, pack the wound with collagen particles, cover it with a calcium alginate patch, then add a silicone border dressing. The order called for this twice a day and as needed.
At 10:56 a.m. on the day of the inspection, Licensed Practical Nurse 2 carried wound care supplies into the room, set them on the side table, and put on a gown and gloves. Aides had just finished showering the resident. The nurse removed the old dressing, sprayed wound cleanser on gauze and cleaned the wound, then took off her gloves and put on a new pair. She applied collagen particles to the wound. She removed those gloves and put on another new pair. She cleaned scissors, cut the calcium patch, applied it, and added the silicone border dressing. She dated the dressing and initialed it.
She had not washed her hands after removing the first pair of gloves, or the second, or at any point in between.
The facility's own hand hygiene policy, updated as recently as February 6, 2026, requires staff to use alcohol-based hand rub or soap after removing gloves and before and after handling wound dressings. The policy is not ambiguous about when hand hygiene applies.
At 11:10 a.m., fourteen minutes after the procedure ended, an inspector interviewed the nurse. She confirmed she should have performed hand hygiene after each glove removal. She had not.
The Assistant Director of Nursing said the same thing when interviewed that afternoon. Licensed Practical Nurse 2 should have washed her hands every time she changed gloves.
The gap between what the nurse knew and what she did is the core of the finding. She was not unaware of the requirement. She could describe it accurately when asked. The procedure simply happened without it.
A stage III pressure ulcer is not a superficial wound. It is an open cavity that exposes tissue below the skin, creating a direct pathway for bacteria to enter the body. Packing such a wound requires inserting material into that cavity. The purpose of changing gloves between steps is to prevent contamination from one surface from being carried to the next. Removing a soiled pair of gloves and immediately putting on a clean pair, without hand hygiene in between, transfers whatever was on the outer surface of the old gloves to the hands, and from the hands to the new gloves.
The inspection covered 24 residents. This was the one deficiency cited.
Scenery Hills did not contest the finding. For information on the facility's plan of correction, CMS directs inquiries to the nursing home or the Pennsylvania state survey agency.
Resident 7 remained at the facility as of the inspection date, cognitively impaired, dependent on staff for daily care, with an open wound on their lower back that required twice-daily packing by the same team of nurses and aides who had just been observed skipping the most basic step in infection prevention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Scenery Hills Rehabilitation and Healthcare Center from 2026-05-29 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 22, 2026 · Our methodology
Scenery Hills Rehabilitation and Healthcare Center in INDIANA, PA was cited for violations during a health inspection on May 29, 2026.
The finding was classified as minimal harm or potential for actual harm, affecting few residents.
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.