State inspectors responding to a complaint found that certified nursing assistants weren't following enhanced barrier precautions when providing care to residents with catheters, feeding tubes, and open wounds. The facility uses these precautions specifically to prevent transmission of multi-drug-resistant organisms that can cause life-threatening infections.
The violations occurred despite clear facility policies and readily available protective equipment. Orange stickers marked the doors of high-risk residents, and organizers containing gloves, gowns, and masks were placed in their rooms for easy staff access.
CNA A told inspectors on November 8 that enhanced barrier precautions were used for residents with insertion devices like catheters and feeding tubes, as well as those with wounds. When asked directly whether staff always wore proper protective equipment when caring for these residents, CNA A said no.
The nursing assistant acknowledged that residents on enhanced barrier precautions were at high risk for infection if protective equipment wasn't worn. CNA A said the charge nurse or director of nursing were responsible for ensuring staff compliance with safety protocols.
CNA B gave similar responses during questioning. The assistant confirmed that enhanced barrier precautions applied to residents with medical devices and wounds, and admitted that staff didn't always wear the required protective gear. Like CNA A, this worker recognized that failing to use protective equipment put high-risk residents in danger of infection.
A third nursing assistant, CNA C, claimed during his interview that he hadn't observed other staff members skipping protective equipment. He said he would speak up if he noticed colleagues not wearing proper gear, and identified supervisors as responsible for ensuring compliance.
The director of nursing, who had held her position for 11 months after two years at the facility, described the enhanced barrier precaution system during her interview. She explained that these protocols applied to residents with insertion devices such as catheters, feeding tubes, or wounds.
The director said she expected staff to wear proper protective equipment when caring for residents on enhanced barrier precautions. She noted that the facility conducted training sessions with staff about which residents required these precautions, and that the information was documented in both the Kardex system and individual care plans.
According to the director, the facility had installed clear signage on residents' doors indicating required precautions, along with organizers containing necessary protective equipment. She emphasized that the facility had plenty of supplies available.
The administrator echoed these explanations during her interview, defining enhanced barrier precautions as protocols for residents with open wounds, feeding tubes, or catheters. She said she expected staff to follow proper precautions and described the orange sticker system and in-room supply organizers.
The administrator identified the infection preventionist as primarily responsible for oversight, while noting that all staff should ensure they followed the precautions. She acknowledged that residents could be at risk for infection if proper protective equipment protocols weren't followed.
The facility's own policy, dated April 1, 2024, defines enhanced barrier precautions as CDC guidance designed to reduce transmission of multi-drug-resistant organisms in healthcare settings, including nursing homes. The policy outlines specific procedures for determining resident risk status, placing appropriate signage, maintaining protective equipment supplies, and ensuring staff awareness.
High-contact care activities requiring enhanced barrier precautions include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, and device care. The policy specifically covers care involving central lines, urinary catheters, feeding tubes, tracheostomies, ventilators, and wound care for any skin opening requiring a dressing.
Despite having comprehensive policies, adequate supplies, clear signage, and staff training programs in place, the facility failed to ensure consistent compliance with life-saving infection control measures. The administrator had identified CNAs A and B as the staff members who weren't following required protocols.
The inspection findings reveal a dangerous gap between written policies and actual practice at Focused Care of Gilmer. While supervisors described robust systems for protecting high-risk residents, frontline staff admitted they weren't consistently using the protective equipment designed to prevent potentially fatal infections in the facility's most vulnerable patients.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care of Gilmer from 2025-11-20 including all violations, facility responses, and corrective action plans.