The violation occurred at Woodstock Valley Health and Rehabilitation on December 2nd when LPN #5 treated Resident #104's sacral wound. The CDC sign on the door clearly stated that providers and staff must wear gloves and a gown for wound care involving "any skin opening requiring a dressing."
When questioned 24 minutes after the wound care, LPN #5 acknowledged the failure. She told inspectors "the sign on the door documented to wear a gown during wound care and she did not."
The resident's medical record revealed the severity of the wound being treated. A physician's note from November 28th documented that Resident #104 presented with a stage four pressure injury on the sacrum. Stage four injuries represent the most severe category of pressure wounds, involving full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone.
A physician's order from December 1st directed staff to "cleanse wound with wound cleanser. Pat dry. Apply medihoney and foam to wound bed QD one time a day for wound care."
The facility's own policy required enhanced barrier precautions for residents with wounds. The policy stated that personal protective equipment "is only necessary when performing high-contact care activities" and specifically identified "wound care: any skin opening requiring a dressing" as a high-contact activity requiring gown and glove use.
Enhanced barrier precautions are designed to reduce transmission of multidrug-resistant organisms in nursing homes. The CDC recommends gown and glove use during high-contact care for residents at increased risk of acquiring these dangerous bacteria, including those with wounds or medical devices.
The inspection found no physician's order specifically directing enhanced barrier precautions for Resident #104, despite the facility's policy stating that such orders should be obtained for residents with wounds like pressure ulcers.
Federal inspectors made facility administrators aware of the violation that same afternoon. The President of Operations, traveling Director of Nursing, and acting Director of Nursing were all notified at 3:24 p.m. on December 2nd.
Stage four pressure injuries carry significant risks for residents. The wounds expose deep tissue and bone, creating pathways for serious infections. Dead skin tissue and rolled wound edges often complicate healing. For elderly nursing home residents with compromised immune systems, proper infection control during wound care becomes critical for preventing life-threatening complications.
The violation occurred despite multiple safeguards meant to ensure compliance. The CDC signage was prominently displayed. Facility policy clearly outlined requirements. The nurse acknowledged understanding the posted requirements.
Yet when the moment came to provide care for one of the most vulnerable types of wounds, the protective barrier that could prevent dangerous bacteria from spreading to other residents was simply omitted.
The inspection classified the violation as having caused "minimal harm or potential for actual harm" to residents. However, infection control failures in nursing homes can have consequences far beyond individual patients, potentially affecting entire facilities when resistant organisms spread between residents and staff.
Woodstock Valley Health and Rehabilitation now faces federal oversight to ensure infection control practices protect residents from preventable complications during their most vulnerable moments of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodstock Valley Health and Rehabilitation from 2025-09-26 including all violations, facility responses, and corrective action plans.
Additional Resources
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