Failure to Maintain Infection Surveillance and Follow COVID-19 QAPI Plan
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program, including accurate monitoring and tracking of infections. Infection control tracking logs were available for June, July, and August 2025 and showed no COVID-19 or TB cases, but there were no infection control logs for September, October, November, and December 2025, or January 2026. Despite this lack of documentation, there were four residents who tested positive for COVID-19 in November 2025, and the Assistant Director of Nursing/Infection Preventionist confirmed that there were no infection control tracking logs or infection location surveillance/maps for those months. The Infection Preventionist also confirmed that there were six residents in isolation for wound infections at the time of the survey, but there was no infection control tracking log documenting the types of infections. The Director of Nursing reported that when the first COVID-19 case was detected on November 23, 2025, staff were notified via WhatsApp and Paycom, residents were notified in person, and families were notified by phone; however, there was no documentation of these notifications. The DON stated the facility did not have a specific COVID-19 policy and instead followed a COVID-19 QAPI Plan that required staff education at the time of a positive case and testing of all residents and staff on days one, three, and five, with the initial positive test date as day zero. The DON confirmed that no additional staff or residents were tested on day one as required, residents were instead tested on days two, four, and nine, and there was no documented evidence of staff testing. The DON also verified that the QAPI Plan’s provisions for expanded testing if additional positives occurred were not followed, and that the only documentation of COVID-19 positive residents was a log emailed to the local health department.
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