The November 5 incident at Focused Care at Westwood involved Resident #1, a cognitively impaired patient who depends entirely on staff for daily care and has multiple medical devices that increase infection risk.
LVN A entered the room at 11:59 AM and performed the wound treatment without donning the mandatory gown and gloves. Federal inspectors observed the violation in real time.
When questioned 31 minutes later, the nurse admitted her mistake. "She forgot to don PPE," according to the inspection report. "LVN A said she realized she should have donned PPE to protect the resident and herself for infection. She knew not donning PPE could cause infection."
The resident requires extensive medical support. He has a suprapubic Foley catheter, severe cognitive impairment with a BIMS score of 04, and needs staff supervision for basic functions like moving in bed and transferring. His care plan states he is "totally dependent on staff for all ADLs" due to weakness and multiple medical conditions.
The facility's Director of Nursing explained that any resident with wounds, contact isolation, gastrostomy tube feeding, or Foley catheters gets placed on Enhanced Barrier Precautions specifically to reduce the spread of multi-drug resistant organisms. She said signage posted at the head of Resident #1's bed clearly explained what protective equipment staff must wear for different tasks.
"Any contact with a resident with pressure ulcer required the use of gown and gloves," the DON told inspectors.
Enhanced Barrier Precautions represent a CDC strategy to combat the growing threat of antibiotic-resistant infections in nursing homes. The facility's own policy, revised in April 2024, requires staff to "wear a gown and gloves while performing high-contact care activities with residents who are infected or colonized with a targeted MDRO or who have open wound or indwelling medical device."
CDC guidelines are explicit about the protocol: "Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens."
The nurse's admission that she "knew not donning PPE could cause infection" underscores the deliberate nature of the safety breach. She promised inspectors she "would be more careful."
Resident #1 represents exactly the type of vulnerable patient these protocols aim to protect. Admitted originally in November 2021 and readmitted recently, he has a history of neuromuscular bladder dysfunction, constipation, orthostatic hypotension, and an unspecified bacterial infection. His quarterly assessment shows he cannot perform cognitive tasks and needs constant assistance.
The facility's policy acknowledges that Enhanced Barrier Precautions exist because of CDC guidance designed for healthcare settings "including nursing homes." Staff received training on these precautions, according to the DON.
But training proved insufficient when LVN A encountered the enhanced barrier precautions sign and chose to ignore it.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm" but noted it "could place residents at risk of cross-contamination and development of infection." The finding affects infection control protocols for the entire facility.
The November 6 inspection occurred in response to a complaint. Inspectors reviewed infection control practices for two residents and found failures in half the cases they examined.
Multi-drug resistant organisms pose particular dangers in nursing home settings where residents often have compromised immune systems and share common areas. The CDC developed Enhanced Barrier Precautions specifically because standard infection control measures proved inadequate against these evolving threats.
For Resident #1, the consequences extend beyond immediate infection risk. His care plan commits to keeping him "clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days."
That commitment requires staff to follow basic safety protocols. LVN A's admission that she "forgot" suggests the 30 seconds needed to put on protective equipment before treating his pressure ulcer somehow escaped her attention, despite the warning sign posted inside his room.
The nurse's promise to be "more careful" offers little comfort for a resident who cannot advocate for himself and depends entirely on staff competence for his most basic medical needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care At Westwood from 2025-11-06 including all violations, facility responses, and corrective action plans.