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:
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.
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.
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.
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.
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