Inadequate Oversight of Infection Prevention and Control Program
Summary
The facility failed to ensure that the designated infection preventionist (IP) provided adequate oversight of the infection prevention and control program, as well as the antibiotic stewardship program. Review of monthly resident surveillance forms revealed incomplete documentation, including missing resolved dates and lack of columns for antibiotic time-outs or implementation of precautions. The IP only documented residents on antibiotics and did not include those who were ill but not receiving antibiotics. For staff surveillance, records showed that eight staff members returned to work before the recommended work restrictions for potential norovirus symptoms, and the required call-in forms were not consistently completed by charge nurses. The IP was unsure of her oversight responsibilities and had no documentation of follow-up when protocols were not followed. Interviews with the IP and the DON confirmed that the IP was not effectively monitoring or ensuring adherence to infection control policies and protocols. The DON expected the IP to provide oversight and education when protocols were not followed but was unaware that these duties were not being performed. Additionally, there was no evidence that the IP was being overseen by an infection control committee, as required by facility policy. The facility's infection prevention and control manual outlined specific surveillance and oversight responsibilities that were not being met, including comprehensive data collection, analysis, and reporting to the appropriate committees.
Penalty
Resources
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Failure to designate a qualified IP for the IPCP. An interim nurse said she could not locate her IP certificate, had not really completed much of the IP duties, and was only enrolled in IP courses. Another admin staff member thought the interim nurse had a current IP certificate and expected the facility to have a designated certified IP. The facility did not provide an IP policy.
Infection Preventionist Lacked Required Specialized Training: The facility failed to ensure the RN serving as the IP had completed the required specialized education in infection prevention and control. Survey review found partial CDC training documentation, but the final test certificate had expired and there was no proof the test was taken and passed. The RN stated they were unsure whether a final test was completed and did not have a passing certificate, and the NHA said they had believed the IP course was completed.
The facility failed to maintain a qualified IP onsite to oversee the infection prevention and control program during two gaps in coverage. Facility records showed one IP was not yet qualified before completing the required education, and another IP had not yet completed the qualifying education after becoming DON, leaving periods when no qualified IP was designated.
Infection Preventionist Failed to Track and Trend Recurrent UTIs: The designated IP did not complete infection surveillance, track or trend infection data, or analyze recurring UTI patterns. The IP stated she mainly reviewed antibiotic orders and entered them into the monthly log, was unsure of infection criteria, and was behind on documentation. Logs showed multiple recurrent UTIs, including repeated E. coli cultures, but there was no documentation of analysis, source identification, or staff education related to the recurring infections.
The facility failed to have a qualified and trained Infection Preventionist for its infection prevention and control program. A staff list did not identify an IP, and the Administrator stated an RNCM was the designated IP, but there was no documentation showing completion of the required CDC Train modules or certification. The Administrator later confirmed there was no verification that the RNCM had completed the appropriate certification to serve in that role.
No qualified Infection Preventionist was designated to oversee the infection prevention and control program. The NHA said the prior IP had left and the DON and an LPN would work on the program, but the DON said they were not taking the role and the LPN could not provide proof of specialized IP training, stating the training was many years old and that they would take it in the upcoming days. The issue affected all 39 residents.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control to be responsible for the Infection Prevention and Control Program (IPCP). During interview, Administrative Nurse E, the interim nurse, stated she could not locate her IP certificate, said that when she accepted the interim position an IP certification was not mentioned, and reported that she had not really completed much of the IP duties at the facility. She also stated she was enrolled in courses for IP at the time. Later, she produced the antibiotic/infection control log binder. Record review showed a Completion for Nursing Home Infection Preventionist Training Course for Administrative Staff A, who stated she thought Administrative Nurse E had a current IP certificate and expected the facility to have a designated certified IP employed there. The facility did not provide a policy for an Infection Preventionist.
Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that RN G, who was acting as the Infection Preventionist, had completed the required specialized education in infection prevention and control. Survey review of the documentation provided for the Infection Preventionist's training found that some modules had certificates of completion from the CDC infection control program, but the CDC training log showed the certificate for the final IP test had expired, indicating the test was not taken within the allowed time after completing the modules. The required IP course did not show that the certification test was taken and passed. When interviewed, RN G stated they were not sure whether they had taken a final test after completing the training modules and did not have a certificate showing they passed the IP test. The Nursing Home Administrator stated they had thought RN G had completed the IP course and that the expectation was for the IP to meet the qualifications required by federal regulations.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) onsite to be responsible for implementing the infection prevention and control program during two periods identified in the survey review: 11/12/25 through 11/24/25 and 4/26/26 through 5/20/26. The facility policy dated 4/30/26 stated that the IP coordinates the development and monitoring of the infection prevention and control program and is employed onsite at least part time. The facility’s IP timeline showed RN Employee E5 responsible from 5/1/24 through 11/12/25, IP Employee E19 responsible from 11/13/25 through 3/5/26, and IP Employee E18 responsible from 3/5/26 to present. However, E19’s certificate for the qualifying education required was dated 11/24/25, leaving a gap before qualification, and facility documentation showed E19 became the DON on 4/26/26. E18’s certificate for the qualifying education required was dated 5/20/26, leaving another gap before qualification. During interview on 6/8/26 at 2:00 p.m., the DON confirmed the two IP designation gaps.
Infection Preventionist Failed to Track and Trend Recurrent UTIs
Penalty
Summary
The facility failed to ensure the designated Infection Preventionist (IP) implemented and monitored the Infection Prevention and Control Program by not conducting infection surveillance, tracking and trending infections, analyzing infection data, or identifying infection control concerns. The IP job description stated the IP was responsible for development, implementation, oversight, and evaluation of the program, but the IP reported she only reviewed physician orders for antibiotics and entered information into the monthly infection tracking log. She stated she did not review resident symptoms when monitoring infections, was unsure what infection criteria were used to identify infections, and had not completed the May 2026 infection control log, stating she was usually about one month behind in documentation. Record review of the urinary tracking infection logs from February 2026 through April 2026 identified 54 UTI episodes, excluding residents admitted with infections and duplicate entries for the same active infection, with multiple residents experiencing recurrent UTIs. The logs included resident names, organisms identified, antibiotic treatment, treatment completion dates, and follow-up culture results, but there was no documentation that the infections were analyzed for trends, contributing factors, recurring organisms, or opportunities for intervention. The logs also showed a recurring pattern of E. coli in urine cultures, yet there was no evidence of surveillance to identify contributing factors, determine the source, or implement corrective interventions. The IP confirmed she had not tracked or trended infections, evaluated recurring infection patterns, analyzed infection data, or provided staff education regarding perineal care, catheter care, hydration, or other interventions related to the recurring infections.
Qualified Infection Preventionist Not Documented
Penalty
Summary
The facility failed to have a qualified and trained Infection Preventionist in place for the infection prevention and control program. A staff list provided on 6/1/26 did not identify an Infection Preventionist. On 6/2/26 at 9:30 AM, the Administrator stated that Staff 12, the RNCM, was the designated Infection Preventionist, but Staff 12 was out of the facility and could not be interviewed. Review of documents provided by the Administrator showed that Staff 12 had completed 11 of 24 modules of CDC Train training, with no indication that the modules were completed and no evidence of a completed certification. When additional information about completion of the training and certification was requested, none was provided. On 6/4/26 at 12:43 PM, the Administrator confirmed there was no documentation verifying that Staff 12 had completed the appropriate certification to serve as the designated qualified Infection Preventionist.
No Qualified Infection Preventionist Designated
Penalty
Summary
The facility did not ensure that one or more individuals were designated as the Infection Preventionist with specialized infection prevention and control training. The facility policy titled, Infection Prevention and Control Program, stated that the designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations. During interviews, the NHA stated the previous Infection Preventionist had recently terminated and that the DON and an LPN would be working on the program together. The DON later stated they were not taking on the role of Infection Preventionist and that the LPN had recently started and would be assisting in the role. The LPN reported having completed training many years ago but could not obtain proof of completion, and later stated the certification was over 15 years old and that they would be taking the training in the upcoming days. The deficiency was identified for all 39 residents.
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