The September 30 incident at Park Place of Belvidere illustrates how staff ignored Enhanced Barrier Precautions designed to prevent transmission of drug-resistant organisms. Federal inspectors found two residents with pressure injuries received care without proper protective measures.
The resident, identified as R2 in inspection records, had developed a Stage 2 pressure injury on his right buttock by July. His medical conditions included Type 2 diabetes, hypertension, and anemia. Treatment records show he received wound care every other day from July 20 through September 30.
At 10:09 AM on the inspection day, V6, a registered nurse, told inspectors R2 had returned from his shower and she would perform his wound care. Inspectors watched as she treated his right buttock wound using only gloved hands, without donning the required gown.
No Enhanced Barrier Precaution signs appeared on R2's door or near his room entrance. No personal protective equipment was stationed outside his room for staff use.
The facility's own policy, implemented in February, explicitly requires Enhanced Barrier Precautions for all residents with wounds. The policy states that staff need protective equipment during "high contact resident care such as wound care: any skin opening requiring a dressing."
A second resident faced the same neglect. R3, a female resident admitted earlier in the year, was identified with a Stage 2 left buttock pressure injury on September 3. Like R2, her room displayed no precaution signs and had no protective equipment available outside.
At 10:21 AM, V3, the facility's wound care nurse, confirmed R3 had a stage 2 pressure ulcer on her left buttock that was present when she arrived. V3 said R3 received daily wound treatment.
The facility's Director of Nursing, V2, who also serves as the Infection Prevention Nurse, acknowledged the violations when questioned by inspectors. At 2:48 PM, V2 confirmed that residents with pressure wounds require Enhanced Barrier Precautions.
"EBP are essentially contact precautions directed at potential exposure to the patient," V2 told inspectors. She explained that gloves and gowns are required during close contact care activities, signs should be posted on patient doors, and the precautions should be documented in resident charts.
V2 emphasized that nursing staff can initiate these precautions without waiting for a doctor's order. She specifically identified wound care as a close contact care activity requiring protection.
Another registered nurse, V8, demonstrated awareness of the requirements when interviewed at 2:43 PM. She told inspectors that staff "are supposed to wear a gown, glove and masks when doing wound treatment to protect themselves" if a resident has any type of wound.
V8 described the standard protocol: when someone requires Enhanced Barrier Precautions, staff enter the order in the computer system, place gowns and protective equipment outside the resident's room, and post signs outside their door.
The facility's Enhanced Barrier Precautions policy specifies that the measures apply to prevent transmission of multidrug-resistant organisms. According to the policy, these precautions should continue "for the duration of the affected resident's stay in the facility or until resolution of the wound."
Both residents had documented pressure injuries requiring ongoing treatment. R2's treatment records span more than two months, from July 20 through September 30. R3 received daily wound care for her injury identified on September 3.
The inspection found that despite clear facility policies and staff knowledge of requirements, basic infection control measures failed at the point of care. The registered nurse treating R2 proceeded with wound care knowing the proper precautions but choosing not to follow them.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm. The findings affected what inspectors described as "few" residents, though the failure to implement basic infection control measures during wound care creates risks for both patients and staff.
The contradiction between written policy and actual practice emerged clearly during the inspection. While the facility had established comprehensive Enhanced Barrier Precautions in February, staff consistently ignored these requirements when caring for residents with open wounds requiring daily treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Place of Belvidere from 2025-11-18 including all violations, facility responses, and corrective action plans.