Glenburnie Rehab: Infection Control Failure Found - VA
That's what a federal inspector documented at Glenburnie Rehab & Nursing Center on the morning of October 28, 2025. At 9:03 a.m., the facility's licensed practical nurse assigned to wound care — identified in the inspection report as LPN #2 — was preparing to treat a resident with chronic wounds and a urinary catheter. No protective equipment was visible. No isolation signage was posted. LPN #2 entered the room and performed wound care anyway.
The resident, identified only as Resident #2, had been living at Glenburnie for 47 days at the time of the inspection. A review of their clinical record found no orders for enhanced barrier precautions at any point during that stay. Not on admission. Not after the chronic wounds were documented. Not after the catheter was placed.
Enhanced barrier precautions are a specific infection control protocol designed to reduce the spread of multidrug-resistant organisms, bacteria that have developed resistance to the antibiotics used to treat them. Residents with chronic wounds or indwelling medical devices like urinary catheters are considered at elevated risk of carrying or acquiring these organisms. The precautions require staff to wear a gown and gloves during hands-on care activities — wound care being one of the clearest examples.
Glenburnie's own policy said as much.
The facility's written Enhanced Barrier Precautions policy, reviewed by inspectors, stated that employees providing high-contact care will follow the precautions for patients with chronic wounds or indwelling medical devices, and that wound care for chronic wounds specifically requires gown and glove use. The policy existed. Nobody followed it for this resident.
The next morning, October 29, inspectors interviewed the facility's director of nursing and its regional director of clinical operations. The director of nursing said enhanced barrier precautions exist to prevent the spread of harmful bacteria from resident to resident. The regional director of clinical operations confirmed the precautions apply whenever a resident has a chronic wound or an invasive device like a Foley catheter.
Both of those conditions applied to Resident #2. Had applied since the day they arrived.
The administrator and director of nursing were formally notified of the findings at 12:20 p.m. that same day. The inspection report notes that no additional information was provided before inspectors left the building.
What the report cannot say is how many times LPN #2 entered that room over 47 days. Wound care is not a one-time event. It is performed on a schedule, sometimes daily, sometimes more often depending on the wound. Each visit without a gown and gloves was another opportunity for bacteria to move, from the resident to the nurse's clothing, or from surfaces in the room to the nurse's hands, and then to the next room, the next resident, the next wound.
Multidrug-resistant organisms spread in exactly this way. They move on hands and fabric. They survive on surfaces. They are, by definition, difficult to treat once a person is infected. The precautions exist because the consequences of not using them can be severe and, in a building full of elderly and medically fragile people, can reach far beyond the original patient.
The inspection covered eight residents in the survey sample. Only Resident #2's care was cited for this failure. The harm level was classified as minimal harm or potential for actual harm, the lower end of the federal scale.
Resident #2 had chronic wounds and a catheter and spent 47 days in a facility where the nurse responsible for their wound care never once put on a gown.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glenburnie Rehab & Nursing Center from 2025-10-29 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 20, 2026 · Our methodology
GLENBURNIE REHAB & NURSING CENTER in RICHMOND, VA was cited for violations during a health inspection on October 29, 2025.
That's what a federal inspector documented at Glenburnie Rehab & Nursing Center on the morning of October 28, 2025.
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.