The November 10 incident at Legacy at Jacksonville involved a cognitively intact woman who relies on staff for all daily activities and has both bowel and bladder incontinence. Federal inspectors watched LVN B and CNA A enter her room to reposition her and provide incontinent care at 10:03 am.
Neither staff member wore protective equipment before touching the resident, despite her feeding tube requiring enhanced barrier precautions. No sign marked her door indicating the special infection control measures were needed.
The next day, CNA A told inspectors she knew the rules. "If a resident needed EBP, there would be a sign on the door and PPE outside the door," she said. She acknowledged the resident "did have a feeding tube and should be on EBP."
She admitted her mistake: "She failed to put on PPE when she and the nurse gave care and by doing so infections could spread."
LVN B made the same admission during her interview 25 minutes later. "Any resident that had a wound, feeding tube, or device like an intravenous catheter should be on EBP," she told inspectors.
She couldn't explain why the resident lacked proper signage and protective equipment outside her room. "She had forgotten when she and CNA A provided care," the inspection report states.
The nurse knew the protocol required "a gown and gloves must be worn with direct contact patient care." She also understood the consequences: "By not following EBP infections could spread."
Both the Director of Nursing and Assistant Director of Nursing were responsible for posting signs and providing protective equipment, LVN B said. But she acknowledged her own responsibility: "She should have known."
The facility's infection prevention program had clear requirements. Enhanced barrier precautions apply to residents with indwelling medical devices including feeding tubes, central lines, urinary catheters, and tracheostomies. The precautions expand standard protective equipment to include gowns and gloves during high-contact care activities.
Director of Nursing, who serves as the infection prevention nurse, blamed a room change. The resident "had moved rooms and they failed to ensure the EBP sign, and PPE followed her," she told inspectors.
She and the Assistant Director of Nursing were responsible for ensuring residents requiring enhanced barrier precautions had proper measures in place. She expected all staff to follow the program "to prevent the spread of infections."
The Administrator said infection control and enhanced barrier precautions were discussed in daily clinical meetings. Staff received verbal notification when residents required special precautions, and signs were posted on doors.
"She expected all staff to always follow the EBP program and if they were unsure, they needed to ask," inspectors documented. The Administrator understood the stakes: "If staff were not following EBP infections could happen."
The facility's enhanced barrier precautions policy, dated April 1, 2024, defines the requirements clearly. The precautions work alongside standard infection control measures and expand protective equipment use during activities that create opportunities for transferring drug-resistant organisms to staff hands and clothing.
The resident at the center of the violation was admitted with a gastrostomy diagnosis, indicating the feeding tube placement was the reason for her nursing home stay. Her October quarterly assessment showed she had intact cognition with a score of 12 on the Brief Interview for Mental Status, meaning she was fully aware of her surroundings and care.
Despite requiring staff assistance for all activities of daily living and experiencing incontinence, her comprehensive care plan from October 8 addressed her feeding tube needs but failed to include enhanced barrier precautions.
No physician's order existed for the enhanced barrier precautions, though facility policy clearly required them for residents with feeding tubes.
The inspection found the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and prevent communicable disease transmission. The violation placed residents at risk for cross-contamination and infection.
Both staff members who provided the improper care understood the rules and acknowledged their failures could spread infections. Yet they proceeded with intimate care of an incontinent resident without basic protective equipment, despite her feeding tube requiring enhanced precautions under facility policy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legacy At Jacksonville from 2025-11-21 including all violations, facility responses, and corrective action plans.