Failure to Maintain Facility-Wide Antibiotic Stewardship and Infection Surveillance
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use as required by its Antibiotic Stewardship Program policy. The policy, last revised in December 2016, required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist or designee, including review of antibiotic utilization, antibiotic orders, clinical documentation confirming infections, infection surveillance logs, microbiology testing, and trends in infection and antibiotic use data. Surveyors found that for eight of nine months reviewed—July, August, September, October, November, and December 2025, and February and March 2026—the facility was unable to provide any infection control data, including listings of antibiotic orders, clinical documentation confirming infections, surveillance logs, or trending of infections. For January 2026, the facility had only a list of residents who exhibited symptoms and were treated with antibiotics, but did not use a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections. During interviews, the DON, who assumed the position on April 13, 2026 and was also expected to function as the Infection Preventionist, reported being unable to locate Infection Control reports, surveillance records, or infection tracking data for July 2025 through April 2026, except for the January list of residents who received antibiotics. The Administrator confirmed that multiple interim DONs had served since July 2025 and acknowledged that tracking of infection control data, including infection trends and antibiotic use, had not been completed, despite the facility’s stated intent for a comprehensive Infection Control Program that included surveillance, tracking, and trend analysis.
Penalty
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Failure to monitor antibiotic use and apply antibiotic stewardship criteria affected three residents. One resident remained on chronic Macrobid prophylaxis for a history of UTIs without available urology notes to support the ongoing order, another resident with a suprapubic catheter received Macrobid despite an infection tracker showing no McGeer criteria met, and a third resident was continued on cephalexin after a hospital discharge even though the DON confirmed the UA did not support a UTI and the antibiotic was unnecessary.
The facility failed to implement an effective antibiotic stewardship program, resulting in multiple residents receiving antibiotics without timely or accurate application of McGeer criteria and incomplete infection surveillance documentation. When the Infection Preventionist (an LPN) was off duty, no one reviewed new antibiotic orders, so residents were started on systemic antibiotics before determining if infection criteria were met or before contacting a physician about non-qualifying cases. One resident with a toe wound was documented as meeting McGeer criteria for a wound infection even though only redness and swelling were recorded, contrary to the requirement for four signs or symptoms. Another resident with a breast abscess was started on Bactrim and topical mupirocin without an infection report form or log entry until several days later, and the form later contained an erroneous fever entry that conflicted with the infection log. A third resident on Levaquin for pneumonia initially lacked a completed McGeer form and log entry, and only later was documented as meeting all required pneumonia criteria, with the LPN acknowledging the review was not done in a timely manner despite an existing antibiotic stewardship policy requiring such review.
The facility failed to implement its antibiotic stewardship program for two residents who were documented in the infection control log as having in-house UTIs and were treated with antibiotics, despite no recorded UTI signs or symptoms in their medical records. For both residents, who had intact cognition and were dependent for ADLs, the infection control log indicated that McGeer’s criteria were met, yet there was no supporting clinical documentation or completed McGeer’s assessments. The DON confirmed the absence of documented UTI symptoms and assessments, even though the facility’s antibiotic stewardship policy required the infection control nurse or designee to review antibiotic utilization to ensure appropriate prescribing and use.
The facility failed to follow its antibiotic stewardship policy and McGeer’s criteria when managing antibiotics for three residents treated for suspected UTIs. One resident with bladder cancer and a catheter continued on Cefuroxime even though she had no documented UTI symptoms, her urine culture showed pseudomonas aeruginosa below McGeer’s CFU threshold, and Cefuroxime was not listed on the sensitivity report; the stewardship form also lacked clear physician attribution and symptom documentation. A second resident with diabetes and CKD received Keflex for a UTI despite only a single mildly elevated temperature, no urinary symptoms, and a culture whose sensitivity report did not include Keflex, with no evidence the prescriber reviewed this mismatch; the DON later acknowledged the stewardship form incorrectly stated repeated fevers and McGeer’s criteria being met. A third resident with diabetes and hypertension was given a full course of Macrobid for a UTI, but no stewardship evaluation was completed and there was no documented physician follow-up after a urine culture showed mixed organisms below McGeer’s CFU threshold, contrary to policy requiring culture results to guide starting, continuing, modifying, or discontinuing antibiotics.
A resident with an indwelling catheter and cognitive impairment was started on Macrobid for a UTI before culture and sensitivity results were available. The MAR showed the resident received Macrobid until the results showed the infection was resistant, and the antibiotic was then changed to Levofloxacin. The DON verified the antibiotic was started before the C&S came back, which was not consistent with the facility’s antibiotic stewardship guidance.
Antibiotic Stewardship Monitoring Deficiencies: The facility failed to thoroughly review antibiotic orders, notify the prescriber when infection criteria were not met, and provide required antibiotic-use education and reporting. Three residents were affected. One resident with an indwelling catheter received Macrobid and then Cipro before culture and sensitivity results were available, another resident’s nitrofurantoin was started before results were received and only part of the ordered course was administered, and a third resident received Macrobid and cephalexin for UTI without culture and sensitivity results. The policy required lab results and the resident’s clinical status to be communicated to the prescriber to determine whether therapy should be started, continued, modified, or discontinued.
Failure to Monitor and Validate Antibiotic Use
Penalty
Summary
The facility failed to follow its antibiotic stewardship program to monitor antibiotic use for three residents reviewed. The report states that the facility did not appropriately evaluate whether antibiotic therapy met McGeer criteria or whether continued antibiotic use remained justified, and that staff relied on existing orders without confirming the clinical basis for treatment. The facility census was 42, and the deficiency affected three of three residents reviewed for antibiotic stewardship. Resident #19 had diagnoses including hydrocephalus and a cerebrospinal fluid drainage device, with no cognitive impairment noted on the MDS. The care plan focused on prophylactic antibiotics related to a history of UTIs, and a physician order dated 11/02/24 showed Macrobid 100 mg daily. Pharmacy recommendations later questioned continued prophylactic use beyond six months and asked for discontinuation, but the physician response stated that urology followed and no change was advised. The DON later stated she could not locate any urology notes and that the resident and spouse reported no urology visit in at least two years; the DON also stated the resident’s last UTI was when she admitted to the facility in 09/2024. Resident #25 had diagnoses including UTI, obstructive and reflux uropathy, BPH with lower UTI, and a suprapubic catheter, and the MDS showed severe cognitive impairment and need for staff assistance with toileting hygiene. After a UA and culture were obtained, the final urine results showed mixed organisms, and Macrobid was ordered for seven days. The infection tracker for the event showed no McGeer criteria checked, and the DON stated the resident did not meet McGeer criteria based on the catheter-change timing. Resident #23 had a chronic indwelling catheter and was receiving an antibiotic on the MDS. Hospital records showed hematuria and an acute UTI diagnosis, and cephalexin was ordered at discharge; however, the facility infection report documented that the resident did not exhibit the required clinical signs for a UTI, and the DON confirmed the hospital urinalysis did not indicate a UTI and that the antibiotic ordered at discharge was unnecessary. The DON also stated she typically continued hospital-ordered antibiotics without confirming whether they were appropriately ordered.
Failure to Implement Effective Antibiotic Stewardship and McGeer Criteria Review
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective antibiotic stewardship program that ensured appropriate antibiotic use and timely application of McGeer criteria. Surveyors found that the Infection Preventionist (an LPN) was off work over a weekend, and during that time multiple residents were started on antibiotics without any determination of whether they met McGeer criteria. The Director of Nursing and the Infection Preventionist acknowledged that when the Infection Preventionist is off, no one performs her infection control duties, including reviewing new antibiotic orders against McGeer criteria. As a result, residents were receiving antibiotics before any assessment of criteria, and the facility was administering antibiotics prior to notifying the physician if criteria were not met or obtaining a rationale for antibiotic use without meeting criteria. One resident had a history of multiple chronic conditions including acute respiratory failure with hypoxia, chronic pain syndrome, hypertension, hyperlipidemia, morbid obesity, syncope, chronic congestive heart failure, depression, GERD, insomnia, osteoarthritis, and weakness. This resident developed a full-thickness wound on the left third toe with serosanguinous drainage, erythema, exposed bone, tenderness, warmth, and slight edema. A wound nurse practitioner ordered clindamycin and transfer to the emergency room for suspected bone involvement and infection; the resident returned on doxycycline for wound infection. The resident was entered on the infection log as meeting McGeer criteria for cellulitis/soft tissue/wound infection, but the McGeer Infection Report Form showed only redness and swelling were documented. The Infection Preventionist incorrectly marked that the infection met McGeer criteria despite only two signs and symptoms being present, instead of the required four, and stated she had been told only one sign or symptom was needed and that she had not done infection control since 2019. Another resident, admitted with diagnoses including above-knee amputation, anxiety disorder, diabetes, hypertension, hyperlipidemia, major depressive disorder, and muscle weakness, was started on Bactrim DS and topical mupirocin for a large, purple/red, hard abscess under the right breast that was warm to touch and afebrile at the time. This resident was not initially entered on the infection log, and no McGeer Infection Report Form was completed when the antibiotic was ordered because the Infection Preventionist was off duty. Several days later, nursing documentation described drainage, yellow slough, surrounding redness, warmth, and a temperature of 99.2°F, and a McGeer Infection Report Form was then completed. The form indicated heat, redness, serous drainage, and fever, but the Infection Preventionist did not indicate on the form whether criteria were met, and the infection log was later revised to show the resident did not meet criteria. The DON later verified that only one temperature above 99°F had been documented, which would not meet the constitutional fever criterion, making the fever marking an error. A third resident was receiving Levaquin for a “culture infection” on an every-48-hour schedule. This resident was not initially listed on the infection log, and there was no completed McGeer Infection Report Form at the time of surveyor review. The Infection Preventionist stated she had started but not completed the form and believed the resident would not meet criteria because of an upper respiratory infection. A subsequent infection report form documented pneumonia, with all three required criteria checked: chest radiograph interpreted as pneumonia or new infiltrate, new or changed lung exam abnormalities, and leukocytosis. A revised infection log then listed this resident as meeting criteria for antibiotic use, with pneumonia, hypoxia, shortness of breath, and gram-negative rods noted. The Infection Preventionist confirmed that the McGeer Infection Report Form was not completed in a timely manner to determine antibiotic stewardship for this resident and that it was not timely identified whether the physician needed to be called if criteria were not met. Review of the facility’s Antibiotic Stewardship Program policy, revised in 2017, showed that all residents with newly diagnosed infections using antibiotics were to be reviewed for appropriate utilization, including review of infection symptoms prior to initiation, consideration of an antibiotic holiday when there was no proof of review, obtaining and reviewing culture and sensitivity results, and discussing results and treatment recommendations with the primary care physician to ensure responsible antibiotic use. The policy also required prescribers to document dose, duration, and indication for all antibiotic use. Despite this policy, the survey findings demonstrated that residents were started on antibiotics without timely or accurate application of McGeer criteria, infection logs were incomplete or delayed, and the Infection Preventionist lacked current knowledge of the criteria and did not consistently communicate with physicians regarding antibiotic appropriateness when criteria were not met.
Failure to Implement Antibiotic Stewardship for Suspected UTIs
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship program to ensure appropriate use of antibiotics, specifically related to urinary tract infection (UTI) management. For one resident admitted in December 2024 and readmitted in September 2025 with diagnoses including heart failure, COPD, and diabetes mellitus, record review showed no documentation of any UTI signs or symptoms in the medical record. Despite this, the infection control log for January 2026 listed the resident as having acquired an in-house UTI and receiving antibiotics from January 27, 2026, to February 3, 2026, and indicated that McGeer’s criteria were met. The DON confirmed there was no documentation of UTI signs or symptoms, and although a urinalysis was ordered on January 19, 2026, there was no documentation of signs and symptoms or a completed McGeer’s assessment for UTI. A second resident, admitted in August 2023 and readmitted in March 2024 with diagnoses including chronic kidney disease, major depressive disorder, and anxiety disorder, similarly had no documentation of UTI signs or symptoms in the medical record. The quarterly MDS showed this resident had intact cognition and was dependent on staff for ADLs. The facility’s infection control log for February 2026 recorded that this resident acquired an in-house UTI and was on antibiotics from February 1, 2026, to February 6, 2026, and again indicated that McGeer’s criteria were met. The DON verified there was no documentation of UTI signs or symptoms and no McGeer’s assessment completed for this UTI. Review of the facility’s undated Antibiotic Stewardship Program policy showed that the infection control nurse or designee was responsible for infection control line listing and review of antibiotic utilization to ensure appropriate prescribing and use of antibiotics, which was not carried out as required in these cases.
Failure to Implement Antibiotic Stewardship and Apply McGeer’s Criteria for UTI Management
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship policy and McGeer’s criteria when monitoring and managing antibiotic use for residents with suspected urinary tract infections (UTIs). For one resident with malignant neoplasm of the urethra, chronic kidney disease, obstructive and reflux uropathy, and an indwelling catheter, the catheter was accidentally dislodged and replaced in the emergency room, where a urinalysis showed blood and leukocytes and the resident was diagnosed with a UTI. She was started on Cefuroxime, which was continued despite the resident denying dysuria, fever, flank pain, chest pain, or dyspnea, and despite a subsequent urine culture showing pseudomonas aeruginosa at levels below McGeer’s threshold and without Cefuroxime listed as an effective antibiotic. The facility’s antibiotic stewardship evaluation documented that McGeer’s criteria were not met but still recorded a physician justification that did not specify which physician provided it or what symptoms were present. For a second resident with diabetes, chronic kidney disease, and an indwelling catheter, an admission order was written for Keflex for a UTI. The facility’s antibiotic stewardship evaluation stated that the resident had a UTI with onset that day, was not experiencing pain related to the infection, and had repeated oral temperatures of 99°F, and concluded that McGeer’s criteria were met based on fevers and a urine culture with at least 10^5 CFU/mL. The urine culture later showed >100,000 CFU/mL of proteus mirabilis, but the sensitivity report did not include Keflex, and facility documentation noted that Keflex’s effectiveness for UTIs depends on local resistance patterns and that culture and sensitivity testing is crucial before prescribing. Keflex was administered until it was discontinued early due to diarrhea, and there was no evidence that the physician reviewed the continued use of Keflex when it was not listed on the sensitivity report. The DON later stated that the stewardship evaluation was marked in error, as the resident had only one slightly elevated temperature and not repeated fevers. For a third resident with diabetes and hypertension, who had a catheter and was sent to the emergency room for decreased urinary output and concern for kidney injury, hospital records documented burning urinary pain but also noted denial of abdominal or flank discomfort, fevers, chills, hematuria, or dysuria. The resident was started on Macrobid for a UTI and completed a five-day course, and a physician progress note indicated the plan to continue Macrobid and follow up on urine culture results to ensure appropriate coverage. The subsequent urine culture showed 10,000–50,000 CFU/mL of pseudomonas aeruginosa and escherichia coli, which did not meet McGeer’s threshold of >100,000 CFU/mL, and there was no evidence of physician follow-up on the antibiotic choice in light of these results. The DON confirmed that an antibiotic stewardship evaluation was not completed for this antibiotic use and that the physician did not reassess the need for Macrobid when the culture results did not support antibiotic therapy, contrary to the facility’s policy requiring communication of culture and sensitivity results to determine whether antibiotics should be started, continued, modified, or discontinued.
Antibiotic started before culture results
Penalty
Summary
The facility failed to follow antibiotic stewardship guidelines when Resident #37 was started on Macrobid before culture and sensitivity results were obtained. The resident was admitted with diagnoses including fracture of sacrum, major depressive disorder, adjustment disorder with anxiety, obstructive and reflux uropathy, and benign prostatic hyperplasia without urinary tract symptoms. The December infection control log showed a urinary tract infection with an onset date of 12/31/25, and a progress note on that date documented that the resident’s urinalysis was reviewed and Macrobid 100 mg twice a day was ordered until culture results were received. The MAR showed the resident received Macrobid from the evening of 12/31/25 through the morning of 01/02/26. A progress note on 01/02/26 documented that the hospital was contacted for final culture and sensitivity results, the nurse practitioner was notified, and new orders were received. The Macrobid was stopped and Levofloxacin 750 mg daily for five days was started after the culture and sensitivity results showed the infection was resistant to Macrobid. The resident’s MDS showed a BIMS score of nine and an indwelling catheter, and the care plan identified the resident as at risk for urinary retention with monitoring for signs and symptoms of UTI. The DON verified in interview that the resident was started on Macrobid before the culture and sensitivity results came back and that the infection was resistant to Macrobid.
Antibiotic Stewardship Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure antibiotic orders were thoroughly researched to determine whether residents met criteria for infection, failed to notify the prescriber when criteria were not met, and failed to provide education and reports regarding antibiotic use to prescribers in accordance with policy. This affected three residents reviewed for antibiotic use out of 11 residents reviewed, in a facility census of 65. The Antibiotic Stewardship policy stated that when a culture and sensitivity is ordered, lab results and the current clinical situation are to be communicated to the prescriber as soon as available to determine whether antibiotic therapy should be started, continued, modified, or discontinued. Resident #3 was admitted with diagnoses including necrotizing fasciitis, acute and chronic respiratory failure, type 2 diabetes, and obstructive and reflux uropathy, and the admission MDS showed the resident was cognitively intact and had an indwelling catheter. The resident was ordered Macrobid for a urinary tract infection, and an infection report documented symptoms including burning pain on urination, frequency, urgency, changes in urine character, and worsening mental or functional status. The MAR showed six doses were given before the antibiotic was changed after the urine culture was discussed with the physician. The record also showed the resident was ordered Cipro, and the Administrator verified the resident was ordered an antibiotic without culture and sensitivity results. Resident #23 was cognitively intact and dependent on staff for toileting and bathing, with an indwelling urinary catheter and care plan interventions to monitor and report signs and symptoms of UTI. A physician note stated preliminary urinalysis results were suspicious for UTI and a broad-spectrum antibiotic was to be started, and nitrofurantoin was ordered for seven days. The MAR showed the medication was not administered until several days later and only eight of the 14 ordered doses were given. Resident #56 had diagnoses including fracture of the left femur, type 2 diabetes, chronic kidney disease, cerebral infarction, obstructive and reflux uropathy, mild protein-calorie malnutrition, and urinary retention, and the MDS showed severely impaired cognition with an indwelling catheter. Macrobid and later cephalexin were ordered for UTI before culture and sensitivity results were available, and an Antibiotic Time Out form documented that the physician was notified of dipstick results and that a urinalysis was not collected; staff also verified the antibiotics were ordered and administered without culture and sensitivity results.
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