CENTER, MO - Federal inspectors documented serious infection control violations at Westview Nursing Home where staff removed required safety signage and failed to wear protective equipment while caring for a vulnerable resident.
Staff Removed Critical Safety Signs
During a May 2025 inspection, surveyors discovered that nursing assistants had removed infection control signs and "germ stickers" from a resident's door and picture, believing the precautions were no longer necessary. The resident required Enhanced Barrier Precautions (EBP) due to having a pressure ulcer on the left buttock and being incontinent of bowel and bladder.
Certified Nursing Assistant H told inspectors: "He/She was not 100% sure if the resident was supposed to be on EBP" and would "look for the germ sticker on the resident's picture by the door, but did not particularly remember if the resident had one or not."
Nursing Assistant C stated there were typically signs on residents' doors directing if Enhanced Barrier Precautions were required, but "did not think the resident was on EBP" because "there was no sign on the outside of the resident's door."
Protective Equipment Requirements Ignored
Federal regulations require specific infection control measures for residents with wounds, chronic infections, or medical devices. These precautions include wearing gowns, gloves, face shields, and booties when appropriate to prevent the spread of infectious organisms.
During the inspection, surveyors observed staff providing incontinence care to the resident without wearing required gowns. The combination of pressure ulcers and incontinence creates significant infection transmission risks, as bacteria from fecal matter can easily contaminate open wounds.
Pressure ulcers are breaks in skin integrity that provide direct pathways for bacterial entry into deeper tissues. When combined with incontinence, these wounds face constant exposure to harmful microorganisms present in bodily waste.
Administrator Confirms Violation
The facility administrator confirmed to inspectors that the resident was indeed supposed to be on Enhanced Barrier Precautions. She acknowledged that "CNAs removed the signs, including the germ sticker from resident's picture, and PPE because they thought the resident was not on EBP."
The administrator stated she expected residents requiring enhanced precautions to have proper signage indicating these requirements, and that protective equipment should be readily available near residents' rooms when needed.
Infection Control Standards
Enhanced Barrier Precautions represent a critical infection prevention strategy in nursing homes. These protocols are specifically designed to prevent transmission of multidrug-resistant organisms and other infectious pathogens between residents, staff, and visitors.
The Centers for Disease Control and Prevention emphasizes that healthcare facilities must implement consistent infection control practices, particularly for residents with compromised skin integrity or multiple risk factors. Proper signage serves as an essential communication tool to ensure all staff understand and follow required precautions.
When staff members are uncertain about infection control requirements, facility protocols should direct them to verify with nursing supervision rather than assume precautions are unnecessary.
Regulatory Response
The violation falls under federal infection prevention and control regulations that require nursing homes to establish and maintain comprehensive programs to prevent the development and transmission of communicable diseases and infections.
Inspectors cited the facility for failing to ensure staff followed established infection control procedures, potentially exposing residents and healthcare workers to preventable infections.
The facility must submit a plan of correction detailing how it will address the identified deficiencies and prevent similar violations in the future.
Federal oversight continues as facilities work to demonstrate compliance with infection control standards essential for protecting vulnerable nursing home populations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westview Nursing Home from 2025-05-21 including all violations, facility responses, and corrective action plans.
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