The violation occurred during afternoon wound treatment on November 25 at Three Meadows Post Acute, where Licensed Practical Nurse #103 and Unit Manager Licensed Practical Nurse #102 provided care to Resident #05 without donning gowns despite a posted sign outside the resident's door indicating enhanced barrier precautions were required.
The resident presented a complex infection risk profile. Medical records showed the patient had been diagnosed with a Methicillin susceptible staphylococcus aureus infection and carried physician orders from October 21 specifically requiring enhanced barrier precautions for high contact resident care, including wound care.
Federal inspectors observed the nurses treating the resident's unstageable sacral wound while wearing only their regular uniforms. When they turned and repositioned the patient during the procedure, both nurses' uniform tops made direct contact with the resident.
Resident #05 had been admitted to the facility in June 2023 with multiple serious conditions. The patient suffered from chronic obstructive pulmonary disease, type two diabetes, late-onset Alzheimer's disease with dementia, and had undergone an above-the-knee amputation of the right leg. Medical assessments revealed severe cognitive impairment and complete dependence on staff assistance for basic functions including toileting, bathing, bed mobility, and transfers.
The resident's wound burden was extensive. After returning from a recent hospital stay in October, a nursing assessment documented an above-the-knee amputation site with 16 sutures that appeared well-approximated. However, the patient also presented with an unstageable pressure ulcer on the coccyx, another unstageable pressure ulcer on the left heel, a deep tissue injury of the left lateral foot, and additional injury to the left malleolus.
When questioned immediately after the observed violation, both nurses acknowledged they understood the resident required enhanced barrier precautions during wound care. They also admitted they had not worn gowns while providing the treatment.
The facility's own Enhanced Barrier Precautions policy, revised in March 2024, explicitly states these measures are used to reduce transmission of multidrug-resistant organisms to residents. The policy requires targeted gown and glove use in addition to standard precautions during high contact resident care activities, specifically including wound care.
Three Meadows Post Acute had identified 29 residents requiring enhanced barrier precautions among its census of 83 patients at the time of inspection. The facility's failure to follow its infection control protocols occurred despite clear documentation systems, including posted signage alerting staff to the resident's enhanced precaution requirements.
The violation represents a breakdown in basic infection prevention practices for a particularly vulnerable resident. Quarterly assessments had identified Resident #05 as being at risk for developing pressure ulcers and injuries, and the patient's medical history included protein calorie malnutrition, repeated falls, and peripheral vascular disease in addition to the active infections.
Federal inspectors documented the incident as part of a complaint investigation conducted on December 23. The facility's failure to implement its infection prevention and control program affected one of four residents reviewed for wound care practices.
The nurses' decision to skip protective gowning created potential pathways for cross-contamination between residents. Enhanced barrier precautions specifically target the prevention of multidrug-resistant organism transmission, a critical concern in nursing home settings where vulnerable residents live in close proximity and share common care providers.
Both licensed practical nurses involved in the incident held positions of responsibility within the facility's nursing structure, with one serving as a unit manager. Their acknowledged understanding of the enhanced precaution requirements makes the violation particularly concerning from a facility oversight perspective.
The resident's complex medical presentation, including active staphylococcus infection and multiple open wounds requiring regular treatment, made adherence to infection control protocols especially critical for preventing spread to other residents and staff members.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Meadows Post Acute from 2025-12-23 including all violations, facility responses, and corrective action plans.