The September incident at Goldwater Care Danville involved a severely cognitively impaired resident with Parkinson's disease who had developed infections in pressure sores on his right buttock, left hip, sacrum, and left ankle. The resident, identified as R4 in the inspection report, was completely dependent on staff for eating, toileting, dressing, and mobility.
His physician had ordered contact isolation precautions on September 18 due to wound infections. A contact isolation sign was posted on his door two days later, with masks, gowns, and gloves hanging outside the room.
But on September 20 at 2:50 PM, Licensed Practical Nurse V9 told inspectors she was entering the room without protective equipment to sanitize the bedside table. She walked into the isolation room without donning a gown or gloves.
V9 used her bare hands to turn the bedside table around twice while cleaning the surface. She then left the room without washing her hands or performing any hand hygiene.
Outside the door, she arranged the resident's wound dressing supplies on top of the treatment cart.
Those contaminated supplies were then used by V9 and Registered Nurse V10 to complete pressure ulcer care on the resident's sacrum, right ischium, right buttock, left inner buttock, and right hip.
The resident's medical record shows he had multiple serious conditions including spinal fusion, E. coli infection, methicillin-susceptible Staphylococcus aureus infection, vascular dementia, and difficulty walking. His September assessment documented him as severely cognitively impaired.
Director of Nurses V2 confirmed to inspectors the following day that staff must maintain contact isolation precautions. She stated that staff should wear appropriate protective equipment — specifically gowns and gloves — when entering any contact isolation room.
V2 also confirmed that V9 had contaminated the wound supplies used on the resident's multiple infected pressure ulcers.
The facility's own infection precaution policy, revised in May 2023, requires contact precautions for residents known or suspected to be infected with microorganisms that can be easily transmitted through direct or indirect contact. This includes handling environmental surfaces or resident care items.
Contact isolation is designed to prevent the spread of infections that can be transmitted through touch. When staff fail to follow these protocols, they risk spreading dangerous bacteria and other pathogens to other vulnerable residents.
The resident in this case had already developed multiple pressure ulcers with active infections. Pressure sores typically develop when residents remain in the same position for extended periods, cutting off blood flow to the skin. They can become life-threatening when infected.
Federal inspectors found the violation represented minimal harm or potential for actual harm to residents. The complaint inspection was completed on October 2.
The facility failed to maintain proper infection control procedures despite having clear policies and protocols in place. The contamination occurred even though protective equipment was readily available outside the resident's room.
For a resident already fighting multiple infections and completely dependent on staff care, the breakdown in basic infection control procedures represented a serious lapse in safety protocols designed to protect the most vulnerable patients.
The incident highlights how quickly infection control can break down when staff bypass established safety procedures, even for seemingly routine tasks like cleaning a bedside table.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Goldwater Care Danville from 2025-10-02 including all violations, facility responses, and corrective action plans.