The patient, a female resident readmitted to Forest City Rehab & Nursing Center with the severe tailbone wound, requires enhanced barrier precautions due to her chronic infection. Federal inspectors observed the violation on November 17 during their complaint investigation.
At 12:30 PM that day, certified nursing assistants V5 and V6 entered the woman's room and provided care without putting on the blue gowns mandated for high-contact activities with residents on enhanced barrier precautions. The patient's door displayed clear signage indicating the isolation requirements.
The resident's physician had ordered daily dressing changes using crushed antibiotics and antibacterial solution to treat the infected wound. Her medical record showed the Stage 4 pressure ulcer affected the sacral region at the base of her spine.
When confronted two days later, nursing assistant V5 acknowledged the mistake. "If someone is on EBP then a gown and gloves need to be used during cares," V5 told inspectors. "They should have worn a gown during R117's care."
The facility's infection control preventionist confirmed the seriousness of the oversight. V4 explained that the resident "is on EBP for a chronic wound which is currently being treated for an infection. Gowns and gloves should be worn during high contact care."
Forest City's own enhanced barrier precautions policy, updated in November 2022, explicitly requires gowns and gloves during activities like changing briefs or assisting with toileting for residents with chronic wounds. The policy applies specifically to patients like the woman with the infected pressure ulcer.
A second violation involved a male resident with prostate cancer who had a urinary catheter requiring enhanced precautions. Despite physician orders from July mandating the protective measures, no isolation signage appeared on or near his door during the three days inspectors observed his room.
The man remained in bed with his catheter visible during inspector visits on November 17 at 8:53 AM and 1:27 PM, and again on November 18 at 9:26 AM. Each time, staff would have no visual reminder of the required precautions.
Licensed practical nurse V7 described how the system was supposed to work. "There is a sign posted on the resident's door which identifies what type of isolation the resident is on and what PPE staff are required to wear when providing cares," V7 explained to inspectors.
But for this catheter patient, no such sign existed.
The facility's enhanced barrier precautions policy from April 2025 clearly states the requirements apply to residents with indwelling medical devices including urinary catheters, central lines, feeding tubes, and tracheostomies. The policy also covers patients with chronic wounds, distinguishing them from shorter-lasting injuries covered with simple adhesive dressings.
Enhanced barrier precautions represent a middle ground between standard infection control and full isolation. They require gowns and gloves during high-contact care to prevent transmission of multidrug-resistant organisms that have become increasingly common in nursing homes.
The violations occurred during a complaint investigation, suggesting someone had already raised concerns about infection control practices at the facility. Federal inspectors found the problems affected few residents but posed minimal harm or potential for actual harm.
For the woman with the Stage 4 pressure ulcer, the missed precautions meant potential exposure of her infected wound to contamination or spread of resistant bacteria to other patients. Stage 4 pressure ulcers extend through skin and tissue to underlying muscle and bone, creating particularly vulnerable infection sites.
The catheter patient faced similar risks. Urinary catheters create direct pathways for bacteria to enter the body, making proper precautions essential to prevent urinary tract infections and sepsis.
Both residents required the enhanced precautions precisely because their conditions made them high-risk for developing or spreading dangerous infections. The missing gowns and absent signage represented breakdowns in the most basic infection prevention protocols.
The inspection found Forest City failed to properly implement its infection prevention and control program, violating federal requirements that nursing homes maintain effective systems to prevent the spread of infectious diseases among their vulnerable populations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest City Rehab & Nrsg Ctr from 2025-11-19 including all violations, facility responses, and corrective action plans.