State inspectors observed the violation at Avir at Borger on August 26, 2025, during a complaint investigation. The director treated Resident #5's severe coccyx wound — a full-thickness injury extending into muscle, tendon, ligament and bone — without following enhanced barrier precautions that the facility had specifically ordered for this patient.
Resident #5, a cognitively intact male, was admitted to the facility in November 2024 with multiple serious conditions. His medical record showed a stage 4 pressure ulcer at the base of his spine and dysphagia, difficulty swallowing. He also had a colostomy related to chronic wound infection.
The facility's own care plan, updated June 5, 2025, explicitly stated that Resident #5 required enhanced barrier precautions due to his wound and colostomy. The plan specified that personal protective equipment including gowns, gloves and face shields would be available outside his room and in the shower area.
Staff were specifically directed to wear PPE during "high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing, device care or use."
At 9:42 AM on the day of inspection, the director of nursing entered Resident #5's room to perform wound care on his stage 4 pressure ulcer. Inspectors watched as she treated the severe wound without putting on a gown at any point during the procedure.
When questioned 14 minutes later, the director acknowledged her failure to follow protocol. She verified that she had not worn a gown during the wound care and admitted this violated enhanced barrier precautions because the resident had both a wound and a colostomy.
"The DON reported not following EBP would result in violating infection control," inspectors wrote.
The facility's registered nurse explained the purpose of enhanced barrier precautions during an afternoon interview. RN E told inspectors that any resident on enhanced barrier precautions was placed on that protocol "to maintain infection control."
"Anyone with a catheter, wound, or something similar to that should be on EBP which means they should have a station placed outside their room with gowns, gloves, and googles if needed," the nurse said. "EBP was done to prevent the spread of infection."
The charge nurse echoed this understanding the following morning. She told inspectors that enhanced barrier precautions should be used with any resident who has "a catheter, wound, ostomy, PICC line, of something like that." She expected staff to wear appropriate protective equipment for these procedures.
"If staff do not follow EBP then they violate infection control and can spread infections," the charge nurse said.
The facility's own policy, implemented in June 2025, requires enhanced barrier precautions "for the prevention of transmission of multidrug-resistant organisms." The policy specifically lists wound care as a high-contact activity requiring protective equipment, defining it as care for "any skin opening requiring a dressing."
Resident #5's care plan noted he was "at increased risk of a MDRO acquisition due to having a wound." MDRO stands for multidrug-resistant organisms — bacteria that have developed resistance to multiple antibiotics and pose serious health risks, particularly to vulnerable nursing home residents.
Stage 4 pressure ulcers represent the most severe category of bedsores, extending through all layers of skin and into underlying muscle, tendon, ligament or bone. These wounds create significant infection risks and require careful, sterile treatment protocols.
The violation occurred despite clear documentation in Resident #5's medical orders from June 5, 2025: "Enhanced Barrier Precautions - I have a pressure ulcer and colostomy."
Federal regulations require nursing homes to maintain infection prevention and control programs designed to provide safe, sanitary environments and prevent the development and transmission of communicable diseases. The failure to follow basic protective protocols during wound care directly contradicts these requirements.
Inspectors concluded that the director of nursing's failure to wear protective equipment during wound care could place residents at risk of cross-contamination and infections. The violation was classified as causing minimal harm or potential for actual harm.
The inspection found that Avir at Borger failed to maintain proper infection control for one of three residents observed during the complaint investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Borger from 2025-09-12 including all violations, facility responses, and corrective action plans.