Woodside Village Infection Control Violations in ND
GRAND FORKS, ND - Federal inspectors documented multiple infection control violations at Woodside Village nursing home during a January 8, 2025 inspection, finding staff failed to follow proper hygiene protocols during critical medical procedures including tracheostomy care and insulin administration.
Contaminated Glove Use During Tracheostomy Care
The most significant violation involved improper infection control practices during tracheostomy care for a resident with enhanced barrier precautions who had recently experienced an Influenza A infection. On January 9, inspectors observed a nurse performing complex respiratory care while failing to follow basic contamination prevention protocols.
During the observed procedure, the nurse initially followed proper protocol by applying protective gear and completing the sterile portion of tracheostomy care correctly. However, after removing sterile gloves and applying clean gloves for non-sterile care, the nurse's actions created multiple contamination risks.
The nurse removed a used paper napkin that the resident had coughed into, cleaned the tracheostomy site with cotton swabs and cleaning solution, then handed the same contaminated napkin back to the resident. Using the same gloves that had contacted respiratory secretions, the nurse then touched numerous items throughout the resident's room before finally removing protective equipment and leaving.
This sequence violated fundamental infection control principles by failing to change gloves after handling contaminated materials. The facility's own policy clearly states that hand hygiene is required "after contact with blood, body fluids or contaminated surfaces" and emphasizes that "the use of gloves does not replace hand washing/hygiene."
Medical Significance of Tracheostomy Infection Control
Tracheostomy patients face elevated infection risks due to their compromised respiratory systems and direct airway access. The tracheal opening bypasses natural defense mechanisms, making these residents particularly vulnerable to respiratory tract infections and pneumonia. When a patient already has influenza, as in this case, strict infection control becomes even more critical.
Proper tracheostomy care protocols require healthcare workers to treat respiratory secretions as highly infectious material. After any contact with secretions or contaminated surfaces, gloves must be changed and hand hygiene performed before touching other surfaces or continuing care. This prevents cross-contamination that could spread respiratory infections to other vulnerable residents.
The observed violation created multiple infection transmission pathways - from the contaminated napkin back to the resident's hands, from the same gloves to various room surfaces, and potentially to other residents through environmental contamination.
Insulin Administration Without Protective Equipment
A second infection control violation occurred during insulin administration, where inspectors observed a nurse performing injections without wearing gloves. On January 8, a nurse was seen administering both Insulin Glargine and Novolog injections to a diabetic resident after performing hand hygiene but without applying gloves for the procedure.
This practice violates both facility policy and standard medical protocols for injection administration. The facility's insulin injection policy explicitly requires healthcare workers to "apply clean gloves" before administering injections, following proper hand hygiene and equipment preparation.
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
WOODSIDE VILLAGE in GRAND FORKS, ND was cited for violations during a health inspection on January 8, 2025.
On January 9, inspectors observed a nurse performing complex respiratory care while failing to follow basic contamination prevention protocols.
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.