Failure to Monitor and Address Infection Patterns
Penalty
Summary
The facility failed to properly monitor and address patterns and trends of known infections, as evidenced by a review of infection control logs from June to August 2025. During this period, multiple infections were documented, including urinary tract infections, skin infections, fungal infections, osteomyelitis, and respiratory infections, with several instances of the same type of infection occurring in the same units. Despite these documented patterns and trends, there was no evidence that the facility took action to address them, such as staff education, monitoring, or auditing of care practices. An interview with a registered nurse confirmed that no interventions or educational efforts had been implemented in response to these infection trends, and the facility's infection control documentation lacked any indication of efforts to reduce the likelihood of infection spread among the 112 residents.