Glenburnie Rehab: Infection Control Failure Found - VA
The resident she was about to treat had chronic wounds and a Foley catheter, the kind of combination that makes infection specialists nervous. A catheter runs directly into the bladder. Chronic wounds are open entry points. Together, they put a resident at elevated risk of picking up drug-resistant bacteria, the kind that can move from patient to patient on the hands of a caregiver who didn't suit up.
Inspectors from the Centers for Medicare and Medicaid Services arrived at Glenburnie Rehab and Nursing Center on October 28, 2025, and watched the facility's own wound nurse prepare to treat this resident at 9:03 in the morning. There was no protective equipment anywhere in plain view outside the room. The nurse did not put on a gown or gloves before she went in. She did not put them on during the wound care either.
The resident, identified in inspection records only as Resident 2, had been at the facility for 47 days by that point. A review of the clinical record turned up no orders for enhanced barrier precautions at any point during that stay. No documentation that precautions had ever been implemented. Nothing.
Enhanced barrier precautions are a specific infection control measure designed to stop the spread of multidrug-resistant organisms in nursing homes. The CDC recommends them for residents with chronic wounds or indwelling medical devices, exactly the profile of the person lying in that room while the wound nurse worked without protection.
The next morning, inspectors sat down with the facility's director of nursing and its regional director of clinical operations. The director of nursing explained that enhanced barrier precautions exist to stop harmful bacteria from passing between residents. The regional director said the precautions apply to any resident with a chronic wound or an invasive device like a Foley catheter.
Both of them described a system that should have been in place for this resident from the day she was admitted. Neither could explain why it wasn't.
The facility's own written policy said the same thing. Employees providing high-contact patient care, the policy read, will follow enhanced barrier precautions for patients who meet the criteria. Chronic wounds met the criteria. Indwelling medical devices met the criteria. Wound care was listed as one of the specific activities requiring a gown and gloves.
The wound nurse was the person assigned to carry out that care. She was also the person who walked in without any of it.
Inspectors rated the violation as causing minimal harm or the potential for actual harm, the lower end of CMS's harm scale. The finding covered one of eight residents in the survey sample.
What the inspection record doesn't say is whether Resident 2 developed an infection during those 47 days. It doesn't say whether anyone reviewed her case after the lapse was identified, or whether anyone checked the records of other residents to see if the same gap existed elsewhere. When inspectors left the building, no additional information had been provided.
The resident with the chronic wounds and the catheter had spent nearly seven weeks in a facility where the nurse responsible for her wounds never once put on a gown before treating her. The people who run the facility knew what the precautions were for and who they applied to. The policy was written down. The criteria were clear.
The gear just wasn't there.
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.
The resident she was about to treat had chronic wounds and a Foley catheter, the kind of combination that makes infection specialists nervous.
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.