The facility did not follow its infection prevention policy by allowing symptomatic staff, including a CNA and a housekeeper, to work while ill, which contributed to a COVID-19 outbreak affecting all residents on a unit. The outbreak resulted in widespread resident infections and required prolonged isolation precautions, as the facility failed to effectively identify and control the spread of infection.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
The facility failed to maintain an effective infection prevention and control program when infection surveillance logs for multiple months were incomplete or missing key information, including organisms, criteria definitions, and tracking of infections. A COVID outbreak and a gastrointestinal illness involving residents and staff were only partially documented with line lists and an email, without investigation summaries to determine etiology or preventive measures. The designated IP had recently assumed the role and was absent and then terminated, and the ADON, who previously served as IP, reported that there were no documents for tracking and trending infections or outbreaks for the prior three months, although antibiotic use was tracked separately.
The facility failed to maintain a comprehensive infection prevention and control program, resulting in inadequate monitoring of antibiotic use, poor infection surveillance during a COVID-19 outbreak, and improper use of disinfectants due to insufficient staff training. Housekeeping staff were unclear about cleaning chemicals and infection control practices, and documentation of infection surveillance and antibiotic stewardship was missing for several months. Leadership changes and lack of staff accountability further contributed to these deficiencies, and key recommendations from health authorities were not documented or acted upon.
Infection control practices were not followed during a COVID outbreak on a unit with multiple positive residents. Staff had inconsistent masking practices, outbreak testing and tracking were not clearly documented or communicated, and a CNA moved the same wipes between rooms while carrying clean linen against her uniform. A DH also took an entire dental cart with supplies into resident rooms, including isolation rooms.
Failure to Maintain Infection Control Surveillance and Precautions: The DON described an infection surveillance process based on monthly antibiotic lists rather than real-time symptom tracking, and five residents developed respiratory symptoms without being placed on TBP, monitored consistently, or tested for a possible outbreak. One resident had pneumonia with a wet cough and delayed treatment, another had wheezing and low O2 saturation, and others had ongoing cough or congestion without documented illness monitoring. The facility also failed to implement EBP for a resident with dialysis access devices and a resident with a stage 4 pressure ulcer, despite policy identifying those conditions as requiring EBP.
Failure to implement infection control during a GI outbreak. Multiple residents on several units developed loose stools, nausea, and vomiting, and facility records showed no evidence that TBP were put in place for symptomatic residents. An R9 continued to have foul loose stools with stool testing planned for C. diff, while an R33 reported vomiting and feeling awful during observation. Staff interviews showed confusion about which residents were ill, and the Infection Control RN and NHA confirmed the facility did not follow proper surveillance or infection control practices.
Inadequate infection surveillance for staff and resident GI illness. The facility did not maintain an effective system to track staff call-offs for GI and other illness, including missing details such as last worked date, unit assignment, and resident contact, and it did not track housekeeping or therapy staff illnesses. Two residents on the same unit had similar GI symptoms and Imodium orders, but their symptoms were not placed on the line list and a possible GI outbreak was not identified or investigated.
Missing Water Management Program: The facility failed to maintain an infection prevention and control program because it did not have a water management program in place for the current location. The DON/Environmental Services leadership stated the prior location had a comprehensive program, but the new site did not, and the only document provided was an unsigned/incomplete contract with a water management company.
The facility did not report a COVID-19 outbreak to CDPH L&C as required, despite multiple residents and a CNA testing positive. Additionally, a resident's family member was observed assisting with care in a contact precautions room without wearing PPE, contrary to facility policy. Staff confirmed the visitor had not previously reported any PPE allergies, and the facility's infection control policy required PPE use for all visitors in such situations.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.