The violations occurred at Lake Forrest Health, where federal inspectors found staff ignored enhanced barrier precautions designed to prevent disease transmission for a resident with a gastrostomy tube.
Resident ID #1 was admitted in December 2024 with altered mental status, a gastrostomy for artificial nutrition, and seizures. The facility's own policy required all staff to wear gowns and gloves during high-contact care activities for residents with wounds or medical devices.
Clear signage in the resident's room warned staff to wear protective equipment. But family surveillance footage told a different story.
On October 6, 2025, at 9:19 AM, video showed two nursing assistants providing morning care without the required gowns. Two days later, on October 8 at 8:59 AM, one of the same assistants again entered the room to provide care — still without protective gear.
The facility's infection preventionist acknowledged during the October 15 inspection that the resident had been on enhanced barrier precautions since admission specifically because of the gastrostomy. All staff providing care should have been wearing gowns and gloves.
Both nursing assistants admitted their failures when questioned by inspectors. Staff A acknowledged she wasn't wearing a gown while providing care on both October 6 and October 8. Staff B confirmed she also failed to wear required protection on October 8.
Enhanced barrier precautions expand personal protective equipment use beyond situations where blood and body fluid exposure is anticipated. The facility's own policy, dated April 15, 2024, specifically lists dressing changes, bathing, hygiene care, linen changes, and brief changes as activities requiring gown and glove use for residents with medical devices.
The gastrostomy tube creates an artificial opening in the stomach wall to provide nutrition directly to patients who cannot eat normally. Such medical devices increase infection risks, making protective protocols critical for patient safety.
When inspectors interviewed the Director of Nursing Services on October 15, she was unable to provide evidence that the facility maintained an effective infection control program to prevent disease spread for this resident's care.
The family's decision to install video surveillance proved crucial in documenting the violations. Without the footage, the repeated failures to follow infection control protocols might have gone undetected.
Federal regulations require nursing homes to implement infection prevention and control programs designed to help prevent the development and transmission of communicable diseases. The violations at Lake Forrest Health demonstrate how easily such programs can break down when staff fail to follow established protocols.
The inspection found the facility failed to maintain proper infection control for one of one resident reviewed under this citation. While classified as causing minimal harm or potential for actual harm, the violations represent a systemic breakdown in basic safety protocols.
The resident's complex medical conditions — including altered mental status and seizures alongside the gastrostomy tube — made proper infection control even more critical. Patients with compromised health status face higher risks from healthcare-associated infections.
Staff interviews revealed knowledge of the requirements but consistent failure to implement them. Both nursing assistants understood they should have been wearing protective gowns but chose not to during multiple care episodes.
The facility's inability to demonstrate an effective infection control program suggests broader systemic issues beyond individual staff failures. Proper oversight and monitoring systems should have caught and corrected these violations before family video was needed to document them.
For families considering Lake Forrest Health, these findings raise questions about whether basic safety protocols are consistently followed when no one is watching.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Haven Operations LLC Dba Lake Forrest Health from 2025-12-01 including all violations, facility responses, and corrective action plans.