The violation occurred at Heritage Nursing & Rehabilitation during a November 26 inspection. Federal inspectors found that staff were not implementing Enhanced Barrier Precautions for Resident #2, despite his care plan specifically requiring these protections since July 1.
LVN A was observed helping the resident change positions in bed while wearing only gloves. She did not put on a gown, as required by facility policy for residents with feeding tubes and catheters. The nurse left the facility before inspectors could interview her about the violation.
No signage was posted at the entrance to the resident's room or inside indicating that Enhanced Barrier Precautions were required. The resident, who suffered from cognitive decline, was unable to participate in an interview about his care.
Resident #2 had been admitted with a gastrostomy tube surgically placed in his abdomen for feeding and medications, plus an indwelling urinary catheter. His medical assessment showed he required both devices for ongoing care, placing him at higher risk for infection transmission.
LVN B, identified as the resident's primary nurse, told inspectors she was "unsure if Resident #2 required EBP, but she said he should be on EBP since he had a foley catheter and a G-tube." She could not locate required signage around his room and found no physician's order for the enhanced precautions in his medical record.
The nurse said she was "unsure of the process for implementing EBP at the facility because she was new and only worked occasionally." She had received training on infection prevention but acknowledged that failing to implement proper precautions could lead to resident infections.
The facility's Assistant Director of Nursing told inspectors she was responsible for the infection prevention program but was unaware that Resident #2 lacked a physician's order for Enhanced Barrier Precautions. She said the order "must have been mistakenly discontinued during a recent hospitalization."
She also said the resident previously had signage indicating the need for enhanced precautions but was "unsure why it was not posted." According to facility policy, signs must be displayed outside resident rooms indicating required protective equipment.
The administrator acknowledged that staff should wear both gloves and gowns when providing direct care to residents requiring Enhanced Barrier Precautions. She confirmed that failing to follow proper infection control procedures could result in resident infections.
Heritage's own policy, revised in March 2024, requires Enhanced Barrier Precautions to "employ targeted gown and glove use in addition to standard precautions during high contact resident care activities." The policy specifically mandates posting signs outside resident rooms indicating required protective equipment.
The inspection revealed a breakdown in multiple layers of infection control. The resident's care plan documented the need for enhanced precautions, but no physician's order existed to implement them. Required signage was missing from his room. Staff were not following established protocols during direct care activities.
Federal inspectors classified the violation as having potential for actual harm, noting it could lead to infection or illness. The failure affected the facility's obligation to maintain an infection prevention program designed to provide a safe, sanitary environment and prevent transmission of communicable diseases.
Enhanced Barrier Precautions are specifically designed for residents at higher risk of infection transmission, including those with feeding tubes and urinary catheters. The protocols require healthcare workers to wear gowns and gloves during activities involving close contact with residents or their immediate environment.
The resident's cognitive decline made him particularly vulnerable, as he could not advocate for proper infection control measures or report concerns about his care. His dependence on both a feeding tube and urinary catheter created multiple pathways for potential infection transmission.
The inspection found that while the facility had updated its Enhanced Barrier Precautions policy as recently as March 2024, staff implementation remained inconsistent. The disconnect between written policies and actual practice left vulnerable residents at risk for preventable infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Nursing & Rehabilitation from 2025-11-27 including all violations, facility responses, and corrective action plans.
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