The December 22 inspection at Elevate Health and Rehabilitation revealed the nurse treating a resident's ankle wounds from an August car crash. She cleaned both ankle wounds with the same pair of gloves, removed them, then put on new gloves without washing her hands.
The resident had open wounds on both ankles from the motor vehicle accident. The treatment nurse entered the room without wearing a protective gown, cut off dressings from each ankle, and sprayed wound cleanser on the left ankle wound. She then sprayed the right ankle wound and began wiping it with gauze.
Without changing gloves or washing her hands, she continued cleaning the left ankle wound with the same contaminated gloves. She removed the gloves and immediately put on new ones without performing hand hygiene between the glove changes.
The nurse applied collagen powder to both wounds and wrapped them with gauze before finally washing her hands at the sink.
When inspectors questioned her immediately after the procedure, the treatment nurse said she knew she was supposed to change gloves after cleaning wounds but "wasn't sure about doing hand hygiene after cleaning each wound and after removing her gloves."
She told inspectors she had received education on hand hygiene but would need to check the facility's infection policy before answering more questions. The nurse said she knew she needed to wash her hands before and after providing care but was uncertain whether hand hygiene was required after removing gloves and before putting new ones on.
The facility's Director of Nursing, who also serves as the Infection Preventionist, confirmed the nurse should have performed hand hygiene after removing old dressings, after removing gloves, and before putting on new gloves.
But the nursing director revealed her own confusion about infection control protocols. She told inspectors the facility only placed residents on enhanced barrier precautions if they had chronic wounds, not trauma wounds like the car accident victim's ankle injuries.
The director said she didn't think the resident needed enhanced barrier precautions "because her wounds started out as trauma wounds." She was still trying to determine whether another resident's pressure ulcer qualified as chronic, admitting uncertainty about when protective protocols should apply.
Federal inspectors also observed the treatment nurse caring for a second resident with wounds. Again, the resident's room had no sign indicating enhanced barrier precautions were needed. The nurse entered without protective gear and demonstrated the same hand hygiene failures.
The treatment nurse couldn't locate an order for enhanced barrier precautions for either resident. She told inspectors she wasn't sure whether protective gowns were required, which explained why she didn't wear one during wound care procedures.
Her uncertainty extended beyond protective equipment to fundamental infection control practices. Despite acknowledging she knew basic hand hygiene requirements, she repeatedly expressed confusion about when to wash her hands during wound care procedures.
The nursing director confirmed that proper hand hygiene during wound care requires washing hands before starting procedures, between removing old dressings and applying new ones, and after removing gloves. Yet her own treatment nurse was performing wound care on multiple residents without following these basic safety protocols.
The inspection found the facility failed to implement adequate infection prevention and control procedures. Staff responsible for wound care lacked clear understanding of when protective precautions applied and how to prevent cross-contamination between residents with open wounds.
Both residents remained vulnerable to infection complications from the compromised wound care procedures. The car accident victim's healing ankle wounds faced potential bacterial contamination from improper glove and hand hygiene practices during treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elevate Health and Rehabilitation from 2025-12-22 including all violations, facility responses, and corrective action plans.