The violation occurred during wound care for Resident 56, an Alzheimer's patient who was completely dependent on staff and had developed an unstageable pressure ulcer on his left heel. Federal inspectors observed Licensed Practical Nurse 6 on March 11 washing her hands and putting on clean gloves before treating the wound. She never put on a gown.
The resident had been placed on Enhanced Barrier Precautions in February specifically because of his heel wound. Facility policy required staff to wear both gloves and gowns during high-contact care activities for residents with wounds, regardless of whether they had confirmed drug-resistant infections.
When inspectors questioned Licensed Practical Nurse 6 immediately after the wound treatment, she confirmed she had not worn a gown. She said she "did not think that she need to wear any other PPE for the dressing change."
The facility's Infection Control Preventionist later confirmed to inspectors that the nurse should have worn a gown during the wound treatment.
Enhanced Barrier Precautions represent a significant shift in federal infection control guidance. The Centers for Disease Control updated recommendations in April 2024 to require protective gowns and gloves during wound care for any resident with chronic wounds or medical devices, not just those with confirmed drug-resistant infections.
The precautions target what CDC calls "high contact resident care activities" where staff have extensive physical contact with residents or their immediate environment. Drug-resistant organism transmission is common in nursing homes, contributing to substantial resident illness and death as well as increased healthcare costs.
Somerset Healthcare had updated its own policy on Enhanced Barrier Precautions in February 2025, one month before the inspection. The policy stated that gowns and gloves must be applied before performing high-contact care activities, not just before entering a resident's room.
Resident 56's medical history made proper infection control particularly critical. A quarterly assessment from February 2024 showed he had no speech and was rarely understood. He required complete assistance with all daily activities. His diagnoses included Alzheimer's disease and brain dysfunction in addition to the pressure ulcer.
The pressure ulcer on his left heel was classified as "non-stageable," meaning inspectors could not determine the depth of the wound. Care plan notes from December 2024 linked the wound to his immobility. By February 2025, his care plan specifically noted he was on Enhanced Barrier Precautions because of the heel area.
Physician's orders from February 11, 2025, formally placed the resident on Enhanced Barrier Precautions for the pressure area on his left heel. The orders came one month before inspectors witnessed the nurse skipping the required gown during wound treatment.
The violation affected wound care for both the resident's left heel and left great toe during the observed treatment session. Licensed Practical Nurse 6 performed the complete wound treatment without the protective gown that facility policy required.
Federal guidance emphasizes that Enhanced Barrier Precautions must remain in place for the duration of a resident's stay or until wounds heal or medical devices are removed. The precautions specifically target the spread of multidrug-resistant organisms that have become increasingly common in nursing facilities.
The CDC's July 2022 guidance on preventing spread of drug-resistant organisms noted that these infections contribute to substantial resident illness and death. Enhanced Barrier Precautions use targeted protective equipment during high-risk care activities rather than full isolation precautions.
Somerset Healthcare's February 2025 policy acknowledged that Enhanced Barrier Precautions were "necessary when performing high contact resident care" and specifically listed wound care as an indication for the precautions. The policy stated that protective equipment "remain in place for the duration of the resident's stay or until resolution of the wound."
The facility policy also specified that Enhanced Barrier Precautions were indicated for residents with any wounds, not just those with confirmed infections. This aligned with updated federal guidance that expanded precautions beyond residents with known drug-resistant organisms.
When inspectors interviewed the facility's Infection Control Preventionist on March 11, she confirmed that Licensed Practical Nurse 6 should have worn a gown during Resident 56's wound treatment. The preventionist's confirmation came after the nurse had already told inspectors she did not think additional protective equipment was necessary.
The inspection found Somerset Healthcare failed to maintain an infection prevention and control program designed to provide a safe environment and prevent transmission of communicable diseases and infections. The violation was classified as causing minimal harm with potential for actual harm, affecting few residents.
Resident 56 had been living with his pressure ulcer since at least December 2024, when care plan notes first documented the wound. The ulcer was not present when he was admitted to the facility, meaning it developed during his stay at Somerset Healthcare.
The resident's complete dependence on staff for all care made proper infection control protocols essential during wound treatment. His inability to communicate effectively meant he could not advocate for proper care or report concerns about infection control practices.
Federal inspectors reviewed 37 residents during their March inspection of Somerset Healthcare. The infection control violation affected one resident, but represented a breakdown in basic safety protocols designed to protect the facility's most vulnerable patients from dangerous infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Somerset Healthcare & Rehabilitation Center from 2025-03-13 including all violations, facility responses, and corrective action plans.
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