Inadequate Infection Prevention Oversight and Documentation
Summary
The facility failed to ensure that the designated infection preventionist (IP) had sufficient time and competency to oversee the infection prevention and control program. The IP was responsible for multiple duties, including wound care, supply ordering, and occasionally working floor shifts, which limited her ability to focus on infection control tasks. The IP reported not having enough time to complete her infection control responsibilities and lacked documentation of competencies related to oversight of the infection control program. Surveillance logs maintained by the IP were incomplete, missing critical information such as infection onset dates, symptoms, culture results, antibiotic time outs (ATO), and follow-up on the effectiveness or appropriateness of prescribed antibiotics. The IP only documented infections treated with medication and did not monitor all infections as required. Multiple instances were identified where residents with infections did not have complete documentation regarding cultures, causative organisms, isolation precautions, or ATOs. For example, one resident was prescribed antibiotics for both a viral and bacterial infection without clear justification, and another resident with a surgical site infection was not placed on enhanced barrier precautions upon return from the hospital. There was also a lack of evidence that the facility followed up on culture results or communicated with providers regarding antibiotic appropriateness. Additionally, the facility's antibiotic stewardship policy did not specify how the IP should monitor or communicate with providers about antibiotic use, and there was no evidence that the policy had been updated since 2022 to reflect current standards. Employee infection surveillance was also deficient. An employee diagnosed with Strep throat worked while symptomatic and returned to work without documentation of meeting criteria for return, such as being fever-free and having received antibiotics for the recommended period. The facility lacked a policy specifying when staff should be excluded from work due to infection. Observations revealed improper handling of soiled linens, with staff failing to bag contaminated items before transport, increasing the risk of cross-contamination. Staff interviews confirmed awareness of proper procedures but admitted to not following them due to being in a hurry. The director of nursing was unaware of the requirement for antibiotic time outs, and the infection preventionist had not performed or documented any such reviews.
Penalty
Resources
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
The facility did not ensure a qualified IP was designated to effectively oversee its antibiotic stewardship program. An LPN identified as the IP had not served in that role for several years, could not produce a current IP certificate, and had not maintained biennial IP training, while the facility’s infection control logs showed noncompliance with antibiotic stewardship requirements, including poor use of hospital documentation and inaccurate McGeer’s evaluations. Another LPN held an IP training certificate but was not yet functioning as IP, and the facility’s IP policy lacked requirements for formal IP certification, ongoing education, and specific guidance on antibiotic stewardship.
The facility failed to designate a staff member with the required qualifications and certification to serve as the Infection Preventionist for its infection prevention and control program, despite having 29 residents. An administrative nurse was identified by administration as the IP and had completed continuing education on Enhanced Barrier Precautions and antibiotic stewardship surveillance, but she confirmed she did not hold an Infection Preventionist certificate. Although the facility maintained an antibiotic administration and stewardship policy, there was no evidence that a properly certified IP was responsible for overseeing the infection prevention and control program.
Surveyors found that the RN designated as the infection preventionist had not completed the required specialized infection prevention and control training. Review of the RN’s training records showed no evidence of IP-specific education, and during interview the RN confirmed she had begun but not finished the required coursework. This was not consistent with the facility’s policy, which requires the IP to be qualified by education, training, certification, or experience and to have completed specialized infection prevention and control training.
Surveyors found that the facility did not have a designated, qualified Infection Preventionist (IP) overseeing the infection prevention and control program. The DON reported that an RN had been assigned the IP role but could not provide information about the program. The RN stated they were newly graduated, had no infection control experience beyond nursing school, were working full-time as a wound care nurse with more than 40 hours per week, could not devote the required 20 hours weekly to IP duties, and had not started IP certification. This resulted in a cited deficiency under F880 for infection control.
Surveyors found that the facility had not formally designated a qualified onsite individual to be responsible for the infection prevention and control program. During an interview, the DON stated that an Infection Control Nurse had recently been hired but was not yet in the role, and that the DON was currently acting as the Infection Control Nurse based on her training. The DON confirmed that there was no designated qualified infection preventionist in place, resulting in noncompliance with applicable management, personnel, and nursing services regulations.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Lack of Qualified Infection Preventionist and Inadequate Antibiotic Stewardship
Penalty
Summary
The facility failed to have a qualified, designated Infection Preventionist (IP) who effectively monitored and implemented the Antibiotic Stewardship Program for all 39 residents. Upon survey entrance, the facility identified an LPN as the IP, but review of the March 2026 infection control log showed the facility did not meet antibiotic stewardship requirements. Documentation revealed a lack of understanding of the need for hospital documentation to support antibiotic use when residents returned from the hospital, and problems with the timing and accuracy of completing McGeer’s evaluations, which led to errors in determining whether residents met criteria for antibiotic use. During interviews, the identified LPN stated she had not performed the IP role since 2019 and was hired in October 2025 as the MDS nurse, later taking over infection control in December 2025 at the request of the former DON. She reported completing an IP course in February 2021 but was unable to provide a certificate, and her former employer could not immediately supply documentation of her training or continuing education. She confirmed she had not renewed her IP training every two years and had only taken standard infection control bloodborne pathogen education through Relias with her former employer. During the survey, the facility did not provide an IP certificate for this LPN, although it did provide an IP Certificate of Training for another LPN who was not yet serving as IP. Review of the facility’s IP policy showed it did not require a certificate of completion of an IP program or ongoing professional education to maintain competency, and it did not specifically address antibiotic stewardship in the nursing home setting.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) with the required training and certification to be responsible for the Infection Prevention and Control Program for a census of 29 residents. During the entrance conference, an administrative staff member identified an administrative nurse as the facility’s IP, stating she was a licensed nurse who had been completing continuing education in infection prevention. Documentation provided by the facility showed that this nurse had completed education on Enhanced Barrier Precautions and implementation of an antibiotic stewardship surveillance plan. In a subsequent interview, the administrative nurse confirmed she had been performing IP duties and participating in continuing education but acknowledged she did not hold an Infection Preventionist certificate, and that the facility’s plan was for her to take the course and obtain the certificate. The facility also had an undated antibiotic administration policy describing appropriate use and stewardship of antibiotics, but there was no evidence that a properly qualified and certified IP had been designated to oversee the infection prevention and control program.
Designated Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) completed the required specialized training for directing the infection prevention and control program. Surveyors’ review of the personnel training record for a registered nurse identified as the facility’s IP showed no evidence of training related to the IP role. In an interview, the RN confirmed she was the designated IP, stated she had started the required training, but acknowledged she had not had time to finish it. The facility’s policy titled “Infection Preventionist Role,” dated 8/2023, specified that the IP or designee is responsible for directing the infection prevention and control program and should have appropriate background and training, be qualified by education, training, certification or experience, and have completed specialized training in infection prevention and control. This lack of completed specialized IP training for the designated RN, as documented in records and confirmed in interview, was inconsistent with the facility’s own policy requirements for the infection preventionist role.
Lack of Qualified and Dedicated Infection Preventionist
Penalty
Summary
The facility failed to ensure there was a designated and qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program, placing residents at risk for unmet infection control issues or care needs. During an interview, the Director of Nursing Services stated that a registered nurse had been assigned the IP role since December 2025 but was unable to provide any information on the facility’s Infection Prevention and Control Program. In a separate interview, the RN reported they were assigned dual roles as Wound Care Nurse and IP, had only recently graduated from nursing school with no infection control experience beyond their schooling, were working over 40 hours per week on wound care, and were therefore unable to dedicate the required 20 hours per week to the IP role. The RN also stated they had not begun the IP certification program. No specific residents or their medical histories were identified in the report, but the deficiency was cited under F880, Infection Control, with reference to WAC 388-97-1620(2)(b)(i)(ii).
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
Surveyors determined that the facility failed to designate a qualified individual onsite who was responsible for implementing infection prevention and control programs and activities. During an interview, the DON reported that the facility had just hired an Infection Control Nurse, but that this person was not yet functioning in the role, and the DON was currently acting as the Infection Control Nurse. The DON stated she had the necessary training but confirmed that the facility had not formally designated a qualified individual or individuals onsite to be responsible for the infection prevention and control program, resulting in noncompliance with state regulatory requirements related to licensee responsibility, management, personnel records, and nursing services. No specific residents or clinical events were described in the report, and no additional details were provided regarding patient conditions or direct care issues associated with this deficiency.
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