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:
Failure to provide mandatory Infection Control training for one NA was identified. Facility policy required compliance with training standards and mandatory infection control in-service education, but the NA’s personnel file did not show annual Infection Control training for the required period. HR confirmed the training was not provided.
The facility failed to ensure that two of six employees had infection control training as part of its IPC program. During an extended survey, the administrator could not provide evidence of training for two CNAs, and record review showed no documentation that they had received infection control training. The DON and regional director later confirmed that all staff should have infection control training.
Failure to provide Infection Control training to five of five direct care staff was identified. The NHA stated that education is tracked by calendar year and that the facility could not locate 2025 education records for the reviewed LPN, NAs, and RN. The HR Director confirmed that the facility failed to provide the required training.
Missing Infection Control Training Documentation for CNAs: The facility did not provide evidence that 5 CNAs received required infection prevention and control training, even though each had worked at the facility for more than 1 year. The HR Director stated HR handled onboarding only and did not track annual training, and the NHA and DOP confirmed there was no evidence of the training, no organized training records, and no Staff Development Coordinator or designee maintaining training documentation.
Failure to Provide Required Infection Control Training: The facility failed to provide annual Infection Control in-service training for five staff members, including NAs, an RN, and an LPN. Personnel files did not show credible training for the review period, and the NHA confirmed the missing training during interview. The facility policy required regularly scheduled in-service classes and documentation of attendance.
Missing Infection Control Training for Multiple Staff: The facility failed to provide required infection prevention and control training for 9 of 17 direct care staff reviewed, including CNAs, LVNs, the Dietary Manager, the Activity Director, and the ADON. Record review showed no evidence of initial hire training for several employees and no annual training for one CNA. Interviews with the ADON, HR, Administrator, and DON confirmed the training was not completed as required, despite a facility policy requiring initial orientation and in-service training on infection prevention and control standards, policies, and procedures.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide mandatory Infection Control training for one of three staff members, Nurse Aide (NA) Employee E3. Facility policy for Continuing Education stated that compliance with the facility’s standards, policies, and procedures is a condition of employment, and the Training Requirements-Infection Control Training policy stated that the facility will include mandatory in-service training as part of its infection control program. Review of NA Employee E3’s personnel record showed a hire date of 4/5/24, and the current file did not contain annual Infection Control in-service training for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed that the facility failed to provide Infection Control training for NA Employee E3.
Missing Infection Control Training for Two CNAs
Penalty
Summary
The facility failed to ensure that two of six employees had infection control training as part of its infection prevention and control program, which is required to include mandatory training with written standards, policies, and procedures. During the extended survey on 5/14/26, surveyors selected a sample of six employees for review of training requirements and asked the facility administrator to provide evidence of each employee’s training. Review of the training records for CNA #6 and CNA #8 showed no evidence that infection control training had been received. On 5/15/26 at 2:06 PM, the findings were reviewed with the DON and regional director, who confirmed that all staff should have training on infection control, and no additional information was provided.
Failure to Provide Infection Control Training
Penalty
Summary
The facility failed to provide Infection Control training to five of five direct care staff reviewed, including an LPN, three NAs, and an RN. During interviews, the NHA stated that staff education is tracked by calendar year from January through December and that the State Agency requested employee education records for the identified staff. The NHA later stated that the facility was unable to find any education records for those employees for the year 2025. The HR Director also confirmed that the facility failed to provide Infection Control training to the five direct care staff members reviewed.
Missing Infection Control Training Documentation for CNAs
Penalty
Summary
The facility did not ensure that required infection prevention and control training was provided to 5 of 5 direct care staff reviewed. The facility’s policy titled, Training Requirements, stated that training content includes written standards, policies, and procedures for the infection prevention and control program, and that documentation of required training is to be forwarded to HR for the personnel file. On 5/4/26, the surveyor reviewed 5 CNAs from the facility’s employee list: CNA-TT, CNA-UU, CNA-VV, CNA-WW, and CNA-XX. These staff members had been hired between 10/30/2024 and 12/4/2024 and had worked at the facility for longer than 1 year, but the facility was unable to provide evidence that any of them had received infection control training. During interviews on 5/5/26, the HR Director stated that HR handled new employee onboarding but did not track annual trainings after hire, and stated there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations both confirmed there was no evidence that infection control training had been provided to staff. The NHA stated that training records were in boxes kept by the previous DON and that the facility had nothing organized for employee trainings. The NHA also confirmed there was no Staff Development Coordinator or designee maintaining a training schedule or documentation of completed trainings.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide Infection Control training for five of five staff members identified in the report: NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8. Review of the facility’s In-Service Training Program policy showed that nurse aide personnel are to participate in regularly scheduled in-service training classes and that attendance is to be recorded on each employee’s Record of In-Service. However, review of the personnel files for each of the five employees did not include credible annual in-service training on Infection Control for the period from 1/1/25 through 12/31/25. The personnel records reviewed showed that NA Employee E4 was hired on 3/20/24, NA Employee E5 on 10/22/19, RN Employee E6 on 5/30/19, LPN Employee E7 on 10/19/15, and NA Employee E8 on 3/9/81. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide Infection Control training for these five staff members. The cited regulations were 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.20(a)(d) Staff development.
Missing Infection Control Training for Multiple Staff
Penalty
Summary
The facility failed to provide mandatory training on the infection prevention and control program standards, policies, and procedures for 9 of 17 direct care staff reviewed. Record review showed no evidence of initial hire infection prevention and control training for CNA K, CNA F, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director, and the ADON, and no evidence of annual infection prevention and control training for CNA E. The personnel files reviewed showed hire dates for each of these employees, but the required infection control training documentation was absent. During interviews, the ADON stated he was not aware the infection control and prevention training had not been completed on his hire date before he started resident care and said staff were assigned training through a computer program. The HR staff member said she was new to the position and was not aware the required infection control training had not been completed for all employees. The Administrator stated staff were initially trained by logging into a website and watching training videos, and acknowledged responsibility for ensuring required orientation and annual training were completed. The DON also stated nursing staff were responsible for receiving infection control training during orientation prior to employment and annually. A facility policy revised 02/2026 required all personnel to participate in initial orientation and regularly scheduled in-service training, including infection prevention and control program standards, policies, and procedures.
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