Failure to Maintain Comprehensive Infection Prevention and Control Program
Summary
The facility failed to maintain a comprehensive Infection Prevention and Control Program, as required by policy and regulatory guidelines. The Director of Nursing (DON) was initially identified as the Infection Preventionist but clarified that she did not hold this role and lacked the necessary infection control training and certification. Instead, a nurse from another facility, who also serves as an Administrator elsewhere, was designated as the Infection Preventionist and only present one day per week. This individual reported being unable to complete essential duties such as staff education due to limited time on-site and was unaware of residents on prophylactic antibiotics. The facility's infection surveillance and tracking practices were not fully implemented, as required by their own policy. Additionally, there were lapses in infection monitoring for residents on prophylactic antibiotics. One resident had a physician's order for Bactrim for urinary tract infection (UTI) prophylaxis, and another had an order for daily Cephalexin for prophylactic use. However, the medical record for the latter did not contain an assessment or care plan to support the use of a prophylactic antibiotic. The Regional Nurse Consultant was unable to locate documentation justifying this antibiotic use. These deficiencies in infection prevention oversight and documentation had the potential to affect all 63 residents in the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Infection preventionist oversight was limited because the IP spent only about 4 to 5 hours per week on infection control duties while also working as a charge nurse, and she said she had not really looked for trends or patterns. The employee illness logs were incomplete, with return-to-work dates left blank, and there was no indication symptomatic staff during a COVID outbreak were tested for COVID or cleared using CDC guidance before returning to work.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
The facility failed to ensure the DON, who was covering the IP role, met the criteria for current certification and ongoing education. The DON had completed IP specialized training with a certificate that expired, and she stated she had done a lot of learning but had not tracked it separately. Training records after the expiration showed limited infection control education hours, while the facility policy required the IP to maintain current knowledge through ongoing education and related infection control activities.
Surveyors found that the facility failed to ensure the designated Infection Preventionist (IP) had defined, dedicated hours to manage the Infection Prevention and Control Program (IPCP). The DON had served as IP for several years and reported working full-time as DON while addressing infection prevention duties "as needed," with occasional extra hours, and the ADON functioned only as backup for 30 hours per week. The Administrator stated the DON worked many additional hours as IP but could not provide documentation due to the salaried status. Facility documents outlined extensive IP responsibilities, including infection surveillance, antibiotic stewardship, vaccination tracking, rounding, education, and regulatory reporting, and specified that IP hours must be at least part-time and based on the facility assessment, yet there was no evidence of designated IP hours consistent with these requirements.
The facility failed to ensure the designated Infection Preventionist completed required IPC training before serving in the role. The Administrator stated there was no certification of completion on file, and the Infection Control Nurse said she had been serving as the Infection Preventionist since July 2025 but had not finished the required modules or received certification. The facility’s CMS Form 671 documented 21 residents in the facility.
The facility failed to ensure that the designated IP had sufficient time and resources to carry out required IPCP responsibilities. The DON functioned as a full-time DON and only part-time IP, while the Infection Control Plan identified the ADON as IP, yet the facility assessment did not define time or resource needs for the role. Infection surveillance data and lists of residents on EBP or TBP were not readily available, and infection tracking logs lacked essential clinical and antibiotic details. There was no evidence of active antibiotic stewardship protocols, monitoring of current disease threats (including influenza, RSV, and COVID-19), or oversight of staff practices such as hand hygiene and PPE use. The ICC did not have documented meetings, input from required members, or review of surveillance data, HAI rates, or annual risk assessments and goals, indicating that core IPCP functions were not being performed.
Infection Preventionist Oversight and Employee Illness Log Deficiencies
Penalty
Summary
The facility failed to ensure its infection preventionist had appropriate time dedicated to oversight of the infection prevention and control program. The infection preventionist stated she had been in the role for less than a year and that her time for infection control depended on staffing needs because she also worked on the floor as a charge nurse. She reported that she typically spent only 4 to 5 hours per week on infection control duties and that she attempted to review infection control information at least weekly, but this was dependent on staffing and whether she had to work on the floor. She also stated she had not really looked for trends or patterns since starting in the role. Review of the January 2026 employee illness log showed multiple staff illness entries, including reports of sore throat, headache, congestion, dizziness, lightheadedness, diarrhea, vomiting, fever, sinus congestion, and cough. The monthly employee illness logs were not completed fully, and the date returned to work was left blank each time. There was also no indication that staff who became symptomatic during a COVID outbreak had been tested for COVID or vetted before returning to work according to CDC guidance. The DON stated she reviewed the infection preventionist's monthly data before QAPI meetings but had not been reviewing the surveillance logs since the new infection preventionist started.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
Infection Preventionist Lacked Current Certification and Documented Ongoing Education
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) met the criteria for current certification and ongoing education. During interview, the DON stated she had completed the Infection Preventionist Specialized Training through an online training site and had received a certificate issued 4/21/21 with an expiration date of 4/21/24. The online training site required either a passing test score of 80% or completion of the course again for recertification, but the DON stated she had done a lot of learning and had not tracked it separately. After a request for infection control training completed after the certification expiration date, the facility provided training records showing sponsored online infection control education totaling two hours in 2024, two hours in 2025, and one hour in 2026. Facility online training modules completed after 4/21/24 totaled 2.35 hours. During a later interview, the DON stated that although she worked 40 hours per week, at least four hours each week were spent covering the IP role for the facility. The facility policy required the IP to be designated for management of the infection prevention and control program, to have completed specialized training, and to maintain current knowledge through ongoing education and access to current infection control practices and regulations.
Inadequate Designation and Hours for Infection Preventionist Role
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a designated Infection Preventionist (IP) worked the required hours to effectively manage the Infection Prevention and Control Program (IPCP) for all 62 residents. The DON reported in interviews that she had served as the facility’s IP for the past five years and was the person in charge of infection prevention, with the ADON serving as backup. The ADON, who was also certified in infection prevention, worked 30 hours per week. The DON stated she worked 40 hours per week in her DON role and focused on infection prevention during her regular workday as needed, occasionally staying an extra hour or two. The Administrator stated the DON was the primary IP and estimated that she worked approximately 60 hours per week, but could not provide timecards or documentation of the actual hours worked because the DON was salaried. Facility documents showed that the IP job description included extensive responsibilities such as infection surveillance, tracking and trending infections, line listing reports, vaccination tracking, antibiotic stewardship oversight, infection control rounding, performance improvement, occupational health, OSHA respiratory protection oversight, pandemic emergency preparedness, infection control and antibiotic stewardship education, mandatory reporting and communication, regulatory compliance, and participation in the Quality Assurance Committee. Another facility document stated that designated IP hours must be at least part-time and determined by the facility assessment to ensure adequate resources for an effective IPCP, and that facilities should determine if the IP should be dedicated solely to the IPCP. Despite these defined responsibilities and expectations for designated IP hours, the facility did not demonstrate that the DON, as the designated IP, had specific, documented, or dedicated hours allocated to fulfill the IP role as required by the facility’s own guidance and regulatory expectations.
Infection Preventionist Lacked Required IPC Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist completed specialized Infection Prevention and Control (IPC) training before performing the role. The facility’s Infection and Prevention Control Program Plan, dated March 2024, states that the Infection Control Professional is a registered nurse with knowledge of epidemiology practices, microbiology, and infectious disease who has completed or shall complete a course in infection control approved by the CDC and directs the Infection Control Program. During interview, the Administrator stated that the Infection Control Nurse had not completed IPC training to her knowledge and could not provide a certification of completion. The Infection Control Nurse stated that she had been the Infection Preventionist since July 2025 and had not yet completed the required training, explaining that she had started some infection control modules but did not finish them all and therefore never received a certification of completion. The facility’s CMS Form 671 dated 3/30/26 documented that 21 residents resided in the facility.
Failure to Provide Effective Infection Preventionist Oversight and IPCP Implementation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the designated Infection Preventionist (IP) fulfilled the required duties and responsibilities for the Infection Prevention and Control Program (IPCP). The DON, who also served as the IP, reported that she was a full-time DON and only a part-time IP, while an ADON was in training to become the IP. The facility’s 2026 Infection Control Plan identified the ADON as the IP responsible for conducting an annual infection control risk assessment and collaborating with the Infection Control Committee (ICC), but the facility assessment listed only one infection control nurse/preventionist, who was also the DON, and did not specify the amount of time or resources needed for the IP role. There was no documented determination of the resources required for the IPCP or evidence that such resources were provided. Review of IPCP documents showed that infection surveillance data was not readily available and that no data existed prior to January 2026. There was no readily available listing of residents requiring Enhanced Barrier Precautions (EBP) or Transmission-Based Precautions (TBP). The surveyors found no evidence of staff oversight to ensure implementation of infection prevention practices such as hand hygiene and adherence to use of personal protective equipment (PPE). Infection tracking logs lacked key information, including the location of infections, symptoms, diagnostic testing obtained, and details of antibiotic therapy such as dose, route, frequency, duration, and evaluation of treatment effectiveness. Further review revealed no evidence of an antibiotic stewardship system as described in facility policy, including protocols to guide antibiotic prescribing practices, documentation of indication, dose, and duration, review of laboratory reports for antibiotic appropriateness, use of infection assessment tools or algorithms, or systems to monitor antibiotic use and resistance patterns. There were no systems or protocols documented to monitor current disease threats such as influenza, RSV, and COVID-19. Additionally, there were no ICC meeting minutes, no evidence of input from required ICC members, and no documentation of reporting surveillance data, healthcare-associated infection (HAI) rates, or infection control compliance metrics to the ICC. There was also no evidence of an annual infection control risk assessment or development of annual goals and performance measures, demonstrating that the IP did not carry out the required functions of the IPCP.
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