The violation centered on a resident with osteomyelitis, a serious bone infection, who had chronic wounds on both feet. One wound measured 5 centimeters long, 4 centimeters wide, and 1 centimeter deep on the bottom of the right foot. A smaller wound affected the left foot.
Despite the resident's infectious condition, facility staff had never implemented Enhanced Barrier Precautions, a federal infection control requirement designed to prevent the spread of multidrug-resistant organisms in nursing homes.
"They had not talked about EBP at the facility," Director of Nursing told inspectors on January 28. "They have not used EBP at the facility for any residents."
The administrator confirmed the facility wasn't following the protocols. "They had not been doing EBP and he did not think they had an EBP policy," according to the inspection report.
Most alarming to inspectors was the Infection Preventionist's response when asked about Enhanced Barrier Precautions: "He had never heard of EBP prior to today."
Certified Medication Technician A described witnessing nurses perform wound treatments without basic protective equipment. "He hardly ever saw any of the nurses use gloves when doing wound treatments," the inspection report stated. "He saw nurses doing wound treatments without a gown on. He didn't even know where the gowns were."
Licensed Practical Nurse A confirmed the facility's inadequate practices during her interview with inspectors. "The facility administration had not told them to use EBP," she said. "He had only been wearing gloves during wound treatments. He had not worn gowns when doing wound treatments."
The infected resident required complex daily wound care for both feet. Physician orders detailed an intensive treatment regimen: cleaning the left plantar area with wound cleanser, applying A&D ointment to dry areas, then foam dressing and kerlix gauze wrapping. The right foot required similar daily cleaning plus calcium alginate dressing cut to fit the wound bed.
Medical records showed the resident had been admitted with an open wound on the left foot and osteomyelitis. A September care plan identified the resident as being at risk for infection related to the foot wound and having "actual impairment to skin integrity related to a chronic foot wound."
The resident's most recent assessment confirmed cognitive function remained intact while documenting open lesions on the feet requiring daily dressing applications.
When inspectors arrived at the resident's room on January 28, they found no Enhanced Barrier Precaution signs posted outside the door. No personal protective equipment was available for staff or visitors entering the room.
During the inspection, the resident wore socks and declined to remove them for examination. The Director of Nursing confirmed the resident "had wounds on the bottom of both his feet."
Enhanced Barrier Precautions became a federal requirement for nursing homes to prevent the transmission of multidrug-resistant organisms between residents. The protocols require staff to wear gowns and gloves when providing care to residents with certain infections or colonizations.
The facility's skin observation tool from January 24 documented both wounds in detail. The left foot showed a callous measuring 1 centimeter in length and width with no depth, while the chronic wound on the right foot had grown to 5 centimeters long, 4 centimeters wide, and 1 centimeter deep.
Federal inspectors classified the violation as having minimal harm or potential for actual harm affecting some residents. The finding suggests other residents at Johnson County Care Center may have been exposed to infectious organisms due to inadequate infection control practices.
The inspection revealed a complete breakdown in infection prevention protocols at the facility, from frontline staff who didn't wear protective equipment to administrators who were unaware such requirements existed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Johnson County Care Center from 2026-01-29 including all violations, facility responses, and corrective action plans.