Preston Residence
Inspection history, citations, penalties and survey trends for this long-term care facility in West Grove, Pennsylvania.
- Location
- 200 Sycamore Drive, West Grove, Pennsylvania 19390
- CMS Provider Number
- 396090
- Inspections on file
- 17
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Preston Residence during CMS and state inspections, most recent first.
An ABHR dispenser was found installed directly above a light switch, an ignition source, in a resident room. The Director of Maintenance confirmed the noncompliant placement, which did not meet NFPA 101 requirements for ABHR dispenser installation.
A surge suppressor was found supplying power to a coffee machine in the Break Room, which was confirmed by the Director of Maintenance. This use of a surge suppressor for a high draw appliance did not comply with NFPA requirements for electrical equipment and power cord usage.
Surveyors found that the emergency preparedness plan did not include required staff names and contact information, as confirmed by document review and an interview with the Director of Maintenance.
Surveyors found that the facility did not provide documentation confirming that fire doors had been inspected within the required 12-month period. The Director of Maintenance confirmed that records of these inspections were not available.
Surveyors found that the facility did not have documentation to verify that a continuous 4-hour exercise of the emergency generator had been performed within the required 36-month period. The Director of Maintenance confirmed the absence of these records, resulting in a deficiency related to emergency electrical system maintenance.
A resident with End Stage Renal Disease did not have this diagnosis accurately documented on their Quarterly MDS assessment, as confirmed by staff and clinical record review.
A resident with acute CHF and acute kidney failure had a physician-ordered daily fluid restriction, with specific amounts assigned to nursing and dining services per shift. The resident's daily fluid intake was not recorded for ten days, and the DON confirmed that the fluid restriction orders were not followed.
Two residents did not receive appropriate medication management: one was given pain medication without documented attempts at non-pharmaceutical interventions, and another received an anti-psychotic without documented monitoring for side effects. The DON confirmed these omissions during interviews.
The facility did not implement Enhanced Barrier Precautions for two residents with specific medical needs, such as a suprapubic catheter and a central line with a surgical wound. Observations showed no PPE or signage outside their rooms, and the DON confirmed the lack of precautions, which are essential to prevent the spread of multidrug-resistant organisms.
Improper Placement of ABHR Dispenser Above Ignition Source
Penalty
Summary
A deficiency was identified when an alcohol-based hand rub (ABHR) dispenser was observed to be installed directly above a light switch, which is considered an ignition source, in Resident Room 336. This placement does not comply with NFPA 101 requirements, which prohibit ABHR dispensers from being installed within one inch of an ignition source. The Director of Maintenance confirmed the location of the dispenser during the surveyor's observation. The deficiency affected one of three smoke compartments within the facility component. No additional information regarding the medical history or condition of the resident in Room 336 was provided in the report.
Plan Of Correction
1. The wall-mounted hand sanitizer dispenser cited was moved on 6/25/25 to a non-outlet, non-switch wall. 2. All dispenser locations were verified to be appropriately mounted on a non-outlet, non-switch wall. 3. All current and new dispensers' locations will be audited once weekly for one month, and bi-weekly for two months. This will be added to the Quarterly PM. 4. All results will be reported to QAPI on a quarterly basis until satisfied that the cited deficient practice has been rectified. 5. The completion date is 8/24/25.
Improper Use of Surge Suppressor for High Draw Appliance
Penalty
Summary
A deficiency was identified when a surge suppressor was observed supplying electrical power to a coffee machine in the Break Room. This observation was made during a facility inspection and was confirmed in an interview with the Director of Maintenance. The use of a surge suppressor for a high draw appliance, such as a coffee machine, does not comply with the requirements for electrical equipment and power cord usage as outlined by NFPA standards. The facility failed to monitor and ensure proper use of surge suppressors in accordance with these regulations.
Plan Of Correction
1. The surge protector was removed on 6/25/25. 2. A facility-wide inspection was conducted to ensure no other surge protectors were inappropriately used on 7/1/25. 3. An audit will be conducted 1 x weekly for 1 month and bi-weekly for 2 months. 4. The audits will be reported to QAPI quarterly or until the deficient practice has been rectified. Education regarding surge protectors will be completed by 7/18 and provided at new employee orientation and annually thereafter. 5. The completion date is 8/24/25. K 0920
Missing Staff Contact Information in Emergency Preparedness Plan
Penalty
Summary
Surveyors determined that the facility failed to include the names and contact information of staff within the physical copy of the emergency preparedness plan. During a document review, it was found that this required information was missing from the plan, which is intended to serve the entire component of the facility. The absence of this information was confirmed during an interview with the Director of Maintenance. This deficiency was identified during a Medicare/Medicaid Recertification Survey. The survey specifically noted that the physical emergency preparedness plan did not contain the necessary staff contact details as mandated by federal regulations. No information about residents or their medical conditions was included in the findings.
Plan Of Correction
1. The name/contact list was located in the original EOP binder. 2. The EOP phone list will be updated as needed or should personnel change. 3. The EOP is reviewed on an annual basis and the contact list will be verified as current. 4. The Facilities Director will verify monthly that the list remains current and document on the audit sheet. This will be maintained in the EOP and reported to the Safety Committee on a monthly basis. 5. The completion date is 9/25/25.
Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation verifying that fire doors had been inspected within the previous 12 months, as required by NFPA 101 and NFPA 80 standards. During an observation and document review, surveyors requested records of annual fire door inspections, but the facility was unable to produce documentation confirming that these inspections had occurred. An interview with the Director of Maintenance confirmed the absence of such documentation for the required period. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
The Fire Door inspection documentation was verified to exist and to have occurred in the last 12 months for the date of 11/12/24. The Fire Door inspections will be conducted annually. Annual inspections will be scheduled through the work order system and maintain NFPA compliance. A notification will be generated through this work order system (TELS). Inspections will be monitored through the work order system for completion and documentation reported to QAPI as completed. An audit of the Life Safety Book will be completed annually to ensure compliance. The completion date is 8/24/25.
Lack of Documentation for 4-Hour Emergency Generator Exercise
Penalty
Summary
The facility failed to provide documentation verifying that a continuous 4-hour exercise of the emergency generator had occurred within the previous 36 months. During a document review, surveyors were unable to locate records confirming that this required test had been completed as mandated by NFPA 110 standards. The absence of this documentation was confirmed during an interview with the Director of Maintenance, who acknowledged that there was no record available to demonstrate compliance with the 4-hour generator exercise requirement. This deficiency affects the entire emergency electrical system component, as the required maintenance and testing procedures are essential for ensuring the generator's reliability in supplying power during emergencies. The lack of documentation means there is no evidence that the generator's performance and endurance have been adequately tested within the specified timeframe.
Plan Of Correction
The 4-hour generator load test has been completed as of 7/2/25. The 4-hour generator load test will be conducted every 36 months. The 4-hour generator load test will be scheduled through the work order system to maintain compliance. The scheduled load tests will be monitored through the work order system for compliance and reported to QAPI as completed. An annual audit will be completed and filed in the Life Safety Book to ensure compliance. The completion date is 8/24/25.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure the accurate completion of Minimum Data Set (MDS) assessments for one resident. Clinical record review showed that a resident with a diagnosis of End Stage Renal Disease did not have this diagnosis documented on their Quarterly MDS assessment dated March 17, 2025. This omission was confirmed during an interview with a licensed employee, who acknowledged that the MDS was inaccurately completed. The deficiency was identified through both clinical record review and staff interview.
Failure to Follow Physician's Fluid Restriction Orders
Penalty
Summary
The facility failed to follow physician's orders for fluid restriction for one resident diagnosed with acute congestive heart failure and acute kidney failure. The physician's order specified a daily fluid restriction of 2000cc, divided equally between nursing and dining services, with specific amounts allocated for each shift. However, a review of the Medication Administration Record showed that the resident's daily fluid allotment was not recorded for a period of ten days. This lapse was confirmed by the Director of Nursing during an interview, indicating that the physician's orders regarding fluid restriction were not adhered to as required by facility policy.
Failure to Use Non-Pharmaceutical Interventions and Monitor Side Effects
Penalty
Summary
The facility failed to ensure that non-pharmaceutical interventions were attempted prior to administering pain medication for one resident. Specifically, a resident with an order for Oxycodone 10 mg every eight hours as needed for moderate to severe pain received the medication on multiple occasions, but there was no evidence in the clinical record that non-pharmaceutical interventions were tried before administering the medication. This was confirmed by the Director of Nursing during an interview, who acknowledged that such interventions were not attempted prior to giving the pain medication. Additionally, the facility did not monitor for side effects during the use of anti-psychotic medication for another resident. This resident, diagnosed with Alzheimer's Dementia, unspecified mood disorders, and anxiety disorder, had an order for Quetiapine 25 mg at bedtime and received the medication daily. However, review of the Medication Administration Record and progress notes showed no documentation of side effect monitoring while the anti-psychotic was administered. The Director of Nursing confirmed in an interview that there was no documentation of side effect monitoring for this medication.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for two residents requiring such measures. Resident 69, who had a suprapubic catheter, and Resident 120, who had a central line and a left knee surgical wound, were not provided with the necessary personal protective equipment (PPE) or signage indicating their need for Enhanced Barrier Precautions. Observations over four days revealed the absence of PPE outside their rooms, and interviews confirmed the lack of precautions. The Director of Nursing acknowledged that these residents were not on Enhanced Barrier Precautions, which is a requirement to prevent the transmission of multidrug-resistant organisms during high-contact care activities.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
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.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
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.
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