F0882

F

Lack of Qualified Infection Preventionist and Inadequate Antibiotic Stewardship

Bellaire, Ohio Survey Completed on 03-17-2026

Penalty

No penalty information released

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.