Inadequate Infection Control Program and Surveillance
Summary
The facility failed to implement an effective infection prevention and control program, which is crucial for identifying and managing communicable diseases and infections. The deficiency was identified through interviews and record reviews, revealing that the facility did not have a surveillance system in place to identify possible communicable diseases or infections. Additionally, there was a lack of training on when and how to use Transmission-Based Precautions and proper infection control practices during resident care activities. This oversight has the potential to impact all 31 residents residing in the facility. The facility's records showed gaps in infection tracking and surveillance, with no documentation for several months in 2024. Furthermore, there was only one formal infection control in-service related to hand hygiene conducted in March 2024. The Director of Nursing (DON) confirmed that no formal infection control in-services or monitoring of infection control practices had been conducted since the departure of the Infection Preventionist in September 2023. During a recent COVID outbreak, the facility did not conduct any formal in-services to review infection control practices or Transmission-Based Precautions, further highlighting the deficiency in their infection control program.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to ensure that a staff member completed mandatory infection prevention and control training, including the written standards, policies, and procedures for the program. Record review showed no evidence of completion in the training logs, and interviews confirmed that HR and department heads were responsible for monitoring annual computerized training, but the staff member had not completed the assigned IPC course.
The facility failed to ensure timely infection control training for 3 of 20 sampled employees. A CNA had documentation of infection control training but lacked evidence of annual QAPI training, and an LPN and another CNA had no documented evidence of infection control training upon hire. The BOM confirmed the missing documentation, and the facility policy required infection control training during orientation and annually.
Missing Infection Control Training for a Nurse Aide. Facility education records for the year reviewed did not include Infection Control training for one of five direct care staff, a Nurse Aide. The NHA stated education is distributed electronically during the calendar year and confirmed the training was not provided.
The facility failed to ensure agency CNA staff had documented infection control training. Record review showed no proof that four agency CNAs had completed the required training, and an Administrative Nurse stated the facility relied on the agency providers to ensure staff education. The facility also could not provide a policy for verifying that all staff had received the required education.
The facility failed to ensure annual infection control training was completed and documented for a dietary server, a lifestyle manager, a physical therapy assistant, and a speech therapist. Review of transcripts showed missing infection control entries for several staff, and a later-submitted document for the lifestyle manager showed training completion but still no infection control training for the following year. The DON said infection control was part of annual staff education, while the HRD acknowledged that multiple staff transcripts did not show the required training.
Missing Infection Control Training Documentation: The facility failed to maintain documented evidence that a CNA completed annual infection control training. During the annual survey, review of the CNA’s employee file showed no proof of 2025 infection control training, and HR later acknowledged the facility could not provide the required documentation. The Staff Educator stated infection control is part of annual training and competency requirements for nursing aides.
Missing Required Infection Prevention Training
Penalty
Summary
The facility failed to provide mandatory infection prevention and control program training, including the written standards, policies, and procedures for the program, for 1 of 23 staff sampled for licensure and training, identified as PT F. Record review showed PT F had a hire date of 01/31/2025, but the facility’s training log contained no evidence that PT F completed infection prevention and control program training. Review of the training log for the previous 12 months also showed no evidence of completion of this required training. During interviews, HR D stated she was newly appointed and did not yet have access to view or run reports on annual training completion in the computerized training system. CHR E stated annual training was computer generated quarterly, staff were emailed about required and delinquent courses, and HR and department heads were responsible for monitoring completion and reporting delinquent staff. The Administrator stated HR was responsible for reporting staff completion of annual computerized training and said PT F had not completed assigned infection prevention and control training. A policy addressing annual employee training was requested from the Administrator and CHR E but was not provided prior to exit.
Missing Infection Control Training Documentation for 3 Employees
Penalty
Summary
The facility failed to ensure timely initial and annual infection control training for 3 of 20 sampled employees. Employee #9, a CNA hired on 08/05/2020, had documentation showing infection control training completed on 09/23/2024, but the personnel record lacked documented evidence of annual QAPI training completed in 2025. Employee #15, an LPN hired on 01/26/2026, had no documented evidence of infection control training completed upon hire. Employee #16, a CNA hired on 04/23/2026, also had no documented evidence of infection control training completed upon hire. During an interview on 06/29/2026, the BOM stated that orientation training occurs upon hire and annual training occurs thereafter, and confirmed that the personnel records for Employees #9, #15, and #16 lacked documented evidence of infection control training completed upon hire and annually. The facility policy titled Nursing Personnel Education and Training, published 11/2016, stated that education for new employees and contract staff is provided as part of orientation and scheduled annually, including infection control training.
Missing Infection Control Training for Nurse Aide
Penalty
Summary
The facility failed to provide Infection Control training to one of five direct care staff reviewed, Nurse Aide Employee E19. Review of the Nursing Assistant - HC position description showed that staff in this role are expected to maintain compliance with yearly education requirements according to facility policies and DOH regulations and to maintain competencies through continued education, including in-service education, programs, floor conferences, and nursing staff meetings. Facility education records for 2025 did not include Infection Control training for Employee E19. During interviews, the Nursing Home Administrator stated that education is distributed electronically for completion during the calendar year and later confirmed that the facility failed to provide Infection Control training to Employee E19.
Failure to Document Infection Control Training for Agency CNAs
Penalty
Summary
The facility failed to ensure agency staff received the required infection control training as part of its infection prevention and control program. During record review on 06/09/26, documentation could not be provided showing that agency CNA M, CNA N, CNA O, and CMA P had completed infection control training. During an interview later that day, Administrative Nurse D stated the two agency providers used by the facility for staffing had said they ensured their staff had the required education. On 06/10/26, the facility also failed to provide a policy related to ensuring all staff had received the required staff education when requested.
Missing Annual Infection Control Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that annual infection control training was completed and documented for four staff members: a dietary server, a lifestyle manager, a physical therapy assistant, and a speech therapist. Review of staffing records and training transcripts showed that infection control training was not listed for the dietary server, the physical therapy assistant, or the speech therapist, and it was not known when those staff members completed the required annual training. The lifestyle manager’s 2025 transcript also did not list infection control training, although an additional document later emailed to the State Agency showed a registration date of 01/04/2025 and completion of the infection control training on 05/06/2025; that document also showed no infection control training for 05/2026. During an interview, the DON stated that staff receive annual module training through eCampus and additional education during weekly meetings, and she identified infection control as one of the annual topics expected for staff. The DON also stated that she had access to staff modules to monitor completion. The HRD reviewed the transcripts and stated that the dietary server was not required to have infection control training, while also acknowledging that the lifestyle manager’s transcript did not show infection control training for 2025 and that the physical therapy assistant and speech therapist did not have infection control training listed in their transcripts. The speech therapist stated that she had received orientation training at the facility, including infection control, resident rights, emergency preparedness, Elder Justice Act, and abuse training, and that there should be a transcript showing completion. However, her 2026 transcript did not list those trainings, and it showed modules on other topics beginning later in March, April, and May 2026. The facility policy titled Staff Development and Orientation-Resident Care stated that all new and existing staff, volunteers, and contractors would receive training on topics including resident rights, abuse, neglect and exploitation, dementia management, and infection control.
Missing Infection Control Training Documentation
Penalty
Summary
The facility failed to ensure staff received infection control training as part of its infection prevention and control program, which includes mandatory training with written standards, policies, and procedures. During the annual survey, record review showed that Certified Nursing Assistant 1 (CNA1) #12’s employee file did not contain documented evidence of infection control training completed in 2025. In an interview, the Staff Educator stated that annual training and competency requirements for nursing aides include infection control and explained that she had developed a training program since her hire in December 2025 to support compliance with annual training requirements. Human Resources later acknowledged that the facility was unable to provide documented evidence of annual infection control training for CNA1 #12.
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