Peak Resources Gastonia: Infection Control Failure - NC
A federal inspector watched the entire procedure on June 17, 2026.
The resident, identified in inspection records only as Resident 7, was on Enhanced Barrier Precautions, a protocol the facility uses specifically to reduce the spread of multidrug-resistant organisms. Those are bacteria that have developed resistance to the antibiotics used to treat them, and urinary catheters create a direct pathway for them to move from a resident's body to a caregiver's clothing and then to the next room, the next resident, the next surface touched.
The facility's own policy, last revised in October 2025, listed urinary catheter care as a high-contact activity requiring a gown. The sign posted on Resident 7's door repeated that instruction. The gowns were stocked in a container mounted on that same door.
Nurse 1 walked in, washed his hands, and put on gloves. He cleaned the catheter insertion site and tubing with a wound cleanser and gauze, then flushed 30 milliliters of acetic acid through the catheter tubing. He removed his gloves, cleaned his hands with sanitizing wipes, and left. He never touched a gown.
When the inspector spoke with him immediately after, at 11:27 that morning, Nurse 1 said he wore a gown only when a resident was placed on contact precautions. He said he did not wear one for residents on Enhanced Barrier Precautions. He said he was not aware that a gown was required for urinary catheter care.
The Infection Preventionist, interviewed that afternoon, said the facility had recently held an educational in-service covering Enhanced Barrier Precautions and other isolation protocols. She said Nurse 1 had signed the attendance sheet. She said the in-service included a review of the EBP signs and their instructions. She said she expected Nurse 1 to have known he needed a gown.
The Director of Nursing said the same thing. So did the Administrator, in a separate interview two hours later.
Three supervisors, all saying they expected the nurse to follow the protocol. One nurse, who had apparently sat through the training, signed his name to the sheet, and then walked into a room with a sign on the door telling him what to do, and did not do it.
The inspection found this deficiency affected a small number of residents and rated the level of harm as minimal. That rating reflects what inspectors could document, not necessarily what the lapse made possible. Multidrug-resistant organisms do not always cause immediate, visible harm. The concern with failures like this one is transmission, the quiet movement of resistant bacteria from one person to another before anyone knows it has happened.
Enhanced Barrier Precautions exist because standard gloves alone are not enough during certain high-contact procedures. A gown protects the nurse's clothing and arms from contamination that gloves cannot cover. When a nurse skips the gown and moves on to the next resident, the next task, the next room, whatever was on the catheter tubing or the insertion site has a way to travel.
Nurse 1 was the only one of four staff members reviewed for infection control practices found to have committed a violation during this inspection. The report does not say whether he received additional training or was disciplined following the finding.
The gowns were on the door. The sign was on the door. The training had been completed, at least on paper. And an inspector stood in the room and watched a nurse provide catheter care to a resident on multidrug-resistant organism precautions without once reaching for either.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peak Resources - Gastonia from 2026-06-17 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
Peak Resources - Gastonia in Gastonia, NC was cited for violations during a health inspection on June 17, 2026.
A federal inspector watched the entire procedure on June 17, 2026.
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.