Family video footage captured two certified nursing assistants at Mira Vista Court providing incontinence care to Resident #1 without wearing gowns, violating Enhanced Barrier Precautions designed to protect vulnerable patients from infectious disease transmission.
The resident, an elderly male admitted after a stroke that affected his right side and ability to swallow and speak, required a feeding tube and was completely dependent on staff for all daily activities. His care plan from May 21, 2025, specifically placed him on Enhanced Barrier Precautions due to his gastric tube and leg wounds.
On September 25, family video showed CNA H providing incontinence care at 5:15 AM without wearing a gown. The same day at 10:42 AM, CNA I also provided incontinence care without the required protective equipment.
Signs posted outside the resident's room clearly indicated Enhanced Barrier Precautions were in effect. Personal protective equipment was stationed directly outside his door.
CNA A, interviewed by inspectors on October 7, explained that Resident #1 was on precautions "because he had a gastric tube as well as a wound on his leg." She said staff had to wear gowns and gloves "to prevent staff from transferring anything infectious from another resident to the resident on precautions."
But when confronted with the video evidence, CNA I revealed she didn't understand what Enhanced Barrier Precautions meant. She knew she had to wear a gown and gloves when caring for Resident #1 but "did not know the reason."
"She did not always wear a gown because she would get busy and forget," according to the inspection report. CNA I acknowledged there was signage outside isolation rooms but said "she did not always pay attention to it."
When shown the September 25 footage, CNA I admitted that if the video showed she didn't wear a gown, "then she must not have worn one."
Inspectors attempted to reach CNA H by phone but were unsuccessful, leaving only a voicemail.
The facility's Assistant Director of Nursing explained that residents with any artificial openings to their bodies were automatically placed on Enhanced Barrier Precautions. This included patients with gastric tubes, urinary catheters, wounds, and IVs.
Staff were required to wear gowns and gloves while providing care to prevent introducing "an infectious agent from another source to the resident that was on isolation precautions," she told inspectors.
After reviewing the family's video footage, the ADON acknowledged the CNAs should have worn proper protective equipment. She said there had been "multiple in-services on infection control, so there was no reason for the staff not knowing when to wear PPE when it was indicated."
The facility's own infection prevention policy, dated May 15, 2023, specifically required Enhanced Barrier Precautions for all residents with indwelling medical devices like feeding tubes, regardless of whether they carried drug-resistant organisms. The policy mandated gowns and gloves during "high-contact resident care activities" including "changing briefs or assisting with toilet."
Enhanced Barrier Precautions expand protective equipment use during care activities that provide opportunities for transferring multi-drug resistant organisms to staff hands and clothing. The protocols are designed to create a barrier between potentially infectious material and healthcare workers who move between patients.
Federal inspectors determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and help prevent disease transmission. The violation carried minimal harm but potential for actual harm to residents.
The stroke patient remained completely reliant on staff for all activities of daily living, making proper infection control protocols critical to his safety. His compromised condition from stroke, feeding tube, and wounds made him particularly vulnerable to healthcare-associated infections.
Family members had installed video monitoring in the resident's room, capturing the September 25 incidents that led to the federal investigation. The footage provided clear evidence of staff failures that might otherwise have gone undetected.
The inspection found that nursing assistants' failure to follow basic infection control procedures could place residents at risk of exposure to infections from other patients, particularly concerning given the facility's vulnerable population of elderly residents with complex medical conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mira Vista Court from 2025-11-21 including all violations, facility responses, and corrective action plans.