The December 19 state inspection at St. Teresa Nursing & Rehab Center found staff violated Enhanced Barrier Precautions designed to prevent the spread of multidrug-resistant organisms among vulnerable residents.
CNA I told inspectors during a 9:39 AM interview that she thought the safety protocols were no longer needed for Resident #3 because her catheter had been discontinued. But LVN H, the charge nurse present during the interview, corrected her immediately.
"The catheter was discontinued," the licensed vocational nurse said. "However, the resident still needs to be on EBP because she had a G-Tube and pressure ulcer."
The nursing assistant then acknowledged her mistake. She said she "was rushing to get residents up for the scheduled Christmas activity this morning and forgot to follow EBP when I entered [Resident #3's] room to assist LVN H turn the resident to the side to check the resident's skin on her buttocks for skin breakdown."
Enhanced Barrier Precautions require staff to wear gowns and gloves during high-contact care activities with residents who have indwelling medical devices like feeding tubes or who have wounds. The protocols are specifically designed to reduce transmission of multidrug-resistant organisms that can spread through direct contact.
The Director of Nursing confirmed during a 9:51 AM interview that all licensed staff and certified nursing assistants had been trained on the requirements. He said Enhanced Barrier Precautions should be followed "when changing briefs or assisting with toileting, turning and repositioning or assisting with bed mobility, if the resident has any indwelling medical device such as G-Tube, or has a history of MDROs and pressure ulcers."
RN N, interviewed at 2:06 PM, said she had also been trained on the protocols and was responsible for monitoring compliance during her rounds. She confirmed that staff should use gowns and gloves during high-contact care activities with residents who have "any type of indwelling medical device, wounds, history of multi-drug-resistant organisms."
Yet the nursing assistant caring for Resident #3 performed none of these safety measures while helping turn and reposition the resident to check for skin breakdown.
The facility's own policy, effective since April 1, 2024, makes clear that Enhanced Barrier Precautions are required for residents with wounds or indwelling catheter devices "even if the resident is not known to be infected or colonized with a MDRO." Feeding tubes are specifically listed as indwelling medical devices requiring the precautions.
The policy states that protective equipment must be worn during activities including "turn and reposition or assist with bed mobility," "changing briefs or assisting with toileting," "providing hygiene," and "device care or use" involving feeding tubes.
Staff must don gowns and gloves for "any other high-contact activity that includes close bodily contact or coming into contact with the indwelling medical device."
The violation occurred during what should have been a routine skin assessment for a resident with multiple risk factors. Resident #3 had both a feeding tube and pressure ulcer, making proper infection control protocols essential to prevent cross-contamination.
The nursing assistant's admission that she was "rushing" residents to a Christmas activity suggests time pressures may have contributed to the safety lapse. Holiday activities at nursing homes often create scheduling pressures that can lead to shortcuts in care protocols.
The inspection found that staff understood the requirements but failed to follow them when caring for one of the facility's most vulnerable residents. The resident's combination of a feeding tube and pressure ulcer created multiple pathways for potential infection transmission.
Enhanced Barrier Precautions were implemented nationwide in nursing homes following research showing that multidrug-resistant organisms can spread rapidly through facilities when staff don't use proper protective equipment during routine care activities.
The failure to use required protective equipment while repositioning Resident #3 placed both the resident and other patients at risk of cross-contamination. Without gowns and gloves, bacteria and other pathogens can transfer from one resident to staff clothing and hands, then spread throughout the facility during subsequent care activities.
State inspectors classified the violation as causing minimal harm or potential for actual harm to a few residents. The finding suggests the safety lapse was caught before any documented infections occurred.
The inspection occurred the same day as the violation, indicating the facility received a complaint that prompted immediate state review of infection control practices during the holiday period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Teresa Nursing & Rehab Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
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