Inadequate Designation and Hours for Infection Preventionist Role
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.
Penalty
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The facility did not ensure a qualified IP was designated to effectively oversee its antibiotic stewardship program. An LPN identified as the IP had not served in that role for several years, could not produce a current IP certificate, and had not maintained biennial IP training, while the facility’s infection control logs showed noncompliance with antibiotic stewardship requirements, including poor use of hospital documentation and inaccurate McGeer’s evaluations. Another LPN held an IP training certificate but was not yet functioning as IP, and the facility’s IP policy lacked requirements for formal IP certification, ongoing education, and specific guidance on antibiotic stewardship.
The facility assigned an RN as Infection Preventionist before she obtained the required certification and without prior formal training. Infection control logs and surveillance maps were incomplete, with several infections, including C. diff and Candida Auris, not documented for multiple months. The previous IP provided only brief on-the-job training and ceased oversight after changing roles. Staff and the infectious disease physician confirmed ongoing issues with infection control documentation and oversight.
The facility did not ensure that the infection preventionist (IP) role was filled by a nurse working at least part-time on-site. Instead, a regional RN served as the IP and was only present once a month, with no clear documentation of required hours for the IP role in the facility assessment.
The facility did not ensure that the staff member overseeing the infection prevention and control program had completed the required specialized training before assuming the role. After the previous IP left, the new IP had to self-train and did not obtain the necessary certification until several months later, leaving the facility without a qualified IP during that period. The job description for the position also lacked a requirement for specialized training.
The facility did not ensure a qualified infection preventionist (IP) was consistently designated or present to oversee the infection prevention and control program. Review of QAPI meetings and staff records showed inconsistent IP participation, lack of documentation for required IP certification, and reliance on staff who were either not regularly onsite or unable to provide proof of qualifications. This affected all residents in the facility.
The facility failed to ensure the Infection Preventionist (IP) was physically present to conduct infection prevention and control duties as required. The IP was only in the building for limited hours over a three-week period, completing some duties remotely while at other facilities. This deficiency had the potential to affect all 75 residents.
Lack of Qualified Infection Preventionist and Inadequate Antibiotic Stewardship
Penalty
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.
Infection Preventionist Lacked Certification and Incomplete Infection Control Documentation
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), a registered nurse, obtained the required Infection Prevention Certificate prior to assuming the role. The IP was hired and began working in the dual role of Infection Preventionist and Wound Care Nurse without prior formal infection prevention training, only receiving on-the-job training from the previous IP for two weeks. The certificate was obtained nearly two months after starting in the position. Additionally, the previous IP ceased oversight and involvement in infection prevention activities after transitioning to a floor nurse role. The facility also failed to maintain accurate and complete infection control logs and surveillance maps. Several infections, including Clostridium Difficile and Candida Auris, were not documented in the logs or maps for multiple months, and the December infection control log was not available for review until the end of the month, with no surveillance map provided. Interviews with staff and the infectious disease physician confirmed ongoing issues with infection control documentation and oversight, with the physician noting a severe problem related to high rates of severe opportunistic infections.
Infection Preventionist Not Present at Least Part-Time
Penalty
Summary
The facility failed to ensure that the infection preventionist (IP) role was conducted by a nurse who worked at least part-time in the facility. The Facility Assessment form did not specify the required number of hours for the IP to be present to implement infection control programs and activities. Documentation showed that a regional registered nurse was designated as the current IP, but she was only present in the building once a month. Interviews with the administrator and the regional RN confirmed that the IP duties were performed monthly on-site, following the departure of the previous staff member who had served as the IP. The facility's Infection Prevention and Control Program policy indicated the existence of an infection control program, but did not address the lack of a qualified, regularly present IP.
Infection Preventionist Lacked Required Training for IPCP Oversight
Penalty
Summary
The facility failed to ensure that the staff member responsible for overseeing the infection prevention and control program (IPCP) had completed the required specialized training in infection prevention and control. The designated Infection Preventionist (IP) began her training in August 2024, but her predecessor left after only eight hours of training, leaving her to learn the role independently. She did not complete the necessary training and obtain her certificate until January 2025. Review of her personnel file confirmed there was no evidence of completed specialized training prior to this date. Interviews with the Director of Nursing (DON) and other staff confirmed that, during the period between the previous IP's departure and the new IP's completion of training, there was no qualified staff member overseeing the IPCP. Additionally, the job description for the Infection Preventionist Director position did not require completion of specialized training before or after assuming the role. This lapse had the potential to affect all 40 residents in the facility.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure that a qualified infection preventionist (IP) was designated and consistently responsible for the infection prevention and control program. Review of QAPI meeting sign-in sheets from March 2024 to February 2025 showed no consistent designation or participation of an IP, except for two months when the Chief Operating Officer (COO) was present. Interviews revealed that the facility did not have a current IP employed, and while the COO and Director of Nursing (DON) claimed to have IP certificates, only the COO could provide evidence of certification. The DON was unable to provide documentation of her IP certificate, and the personnel file for the former Assistant Director of Nursing (ADON), who was reportedly the IP for several months, contained no evidence of IP certification. Further, the COO stated she was only present at the facility one day per week starting in January 2025, and the RN who assisted with infection prevention worked mostly offsite. This lack of a consistently present and qualified IP had the potential to affect all 54 residents in the facility, as there was no assurance that infection prevention and control measures were being properly overseen and implemented during the period reviewed.
Inadequate Presence of Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was physically present in the building to conduct the responsibilities of the infection prevention and control program (IPCP) as required. The review of the employee schedule for Regional Nurse #916, who was in the role of IP, showed that the IP was only in the building for limited hours over a three-week period. Specifically, the IP was present for eight hours in the first week, sixteen hours in the second week, and eight hours in the third week. Interviews confirmed that the IP completed some duties remotely while at other facilities, and the facility considered part-time work as sixteen to twenty-nine hours per week. This deficiency had the potential to affect all 75 residents in the building.
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