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F0882
F

Lack of Certified Infection Preventionist for Infection Control Program

Windsor, North Carolina Survey Completed on 05-28-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to designate a qualified Infection Preventionist (IP) who was certified in infection prevention and control to oversee the Infection Control and Prevention Program. The Assistant Director of Nursing (ADON), who was assigned as the facility's IP, had not yet completed the required certification, having finished only 13 out of 20 modules in the CDC IP program. Both the ADON and the Director of Nursing (DON) were unaware that full certification was required before assuming the IP role, believing that working toward certification was sufficient. The Administrator was also unaware that the ADON lacked the necessary certification. This deficiency had the potential to affect all 72 residents in the facility.

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