The December 30 inspection at Hibbard Skilled Nursing & Rehabilitation Center found staff ignoring their own Enhanced Barrier Precautions policy for Resident #1, who has peripheral vascular disease, chronic venous insufficiency, and chronic right leg ulcers.
When inspectors arrived at 10:37 a.m., they found the resident lying in bed with an exposed right lower leg showing a visible wound treated with betadine. No warning signs were posted on the door or wall outside the room indicating special precautions were needed.
Certified Nursing Assistant #1 told inspectors the resident "is not on EBP or any type of precautions."
That contradicted the resident's own care plan, which stated: "The resident has a history of a venous wound on right lower leg, follow EBP."
The facility's Enhanced Barrier Precautions policy, revised in March, explicitly states that such measures "are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms to residents." The policy requires EBPs for residents with wounds, including chronic wounds like pressure ulcers and venous stasis ulcers.
"EBPs remain in place for the duration of the resident's stay or until resolution of the wound," the policy states. "Signs are posted in the door or wall outside the residents room indicating the type of precautions and PPE required."
None of that happened for Resident #1.
Medical records revealed the resident had active physician orders for multiple wound treatments. A December 17 order directed staff to "cleanse right dorsal foot wound with normal saline, apply santyl and calcium alginate and cover with dry dressing, every day shift for wound care." Another order from December 4 required staff to "cleanse right lower extremity wound, apply betadine and leave open to air, every day shift."
Treatment records showed Registered Nurse #2 had been providing wound care throughout December, including on December 18, 19, 22, 23, 24, 26, 29, and the day of the inspection.
When questioned at 1:49 p.m., RN2 told inspectors "she thinks Resident #1 was on EBP at some point, but that his wounds had also improved at one point, so he was taken off EBP."
The facility's Infection Preventionist offered a different explanation during a 2:30 p.m. interview. She said the facility discusses "all residents with open wounds and devices" every Friday at Risk meetings, and that RN2 "is usually the one who discontinues a resident's precautions because she does the wound treatments."
The Infection Preventionist then claimed "if a wound is not draining the resident would not need to be on EBP."
But facility policy contains no such exception. The written policy requires enhanced precautions for residents with wounds, period. It makes no distinction between draining and non-draining wounds.
The confusion among staff members highlighted a breakdown in the facility's infection control program. While one nurse thought the resident had been removed from precautions due to wound improvement, the certified nursing assistant didn't know precautions had ever been required. Meanwhile, the resident's care plan still mandated enhanced barrier precautions.
Federal regulators found the facility "failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection." The violation carried a designation of "minimal harm or potential for actual harm."
The inspection findings were discussed with the Director of Nursing at 2:45 p.m. on December 30.
For Resident #1, the policy failures meant continued exposure to potential infection risks during routine daily care, despite having multiple chronic wounds that facility policy specifically identified as requiring enhanced protection measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hibbard Skilled Nursing & Rehabilitation Center from 2025-12-30 including all violations, facility responses, and corrective action plans.