St Martha Center For Rehabilitation & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Downingtown, Pennsylvania.
- Location
- 470 Manor Ave, Downingtown, Pennsylvania 19335
- CMS Provider Number
- 395815
- Inspections on file
- 20
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at St Martha Center For Rehabilitation & Healthcare during CMS and state inspections, most recent first.
A resident with urinary and cardiac conditions had physician orders for Foley catheter care every shift, continuous O2 at 2L via nasal cannula, and head-of-bed elevation for SOB that were not carried out on multiple day and evening shifts over an extended period, as evidenced by gaps in the MAR and confirmed by the DON.
The facility failed to follow physician orders for two residents. One resident with dysphagia and malnutrition did not receive the prescribed amount of enteral nutrition via a Kangaroo pump, as the pump was often disconnected early. Another resident with Type II Diabetes Mellitus missed several doses of Insulin Aspart, with no parameters for holding the insulin or physician notification documented. These deficiencies were confirmed by the DON.
The facility failed to ensure appropriate indications and non-pharmacological interventions before administering as-needed anti-anxiety medications for two residents. One resident received Ativan gel without proper indication or non-pharmacological attempts, while another received Clonazepam without appropriate indication or non-pharmacological interventions. These deficiencies were confirmed with the DON.
The facility failed to ensure corridor doors positively latch and resist smoke passage, affecting two smoke compartments. Observations revealed that the Main Street Cafe doors did not latch, and the Sunflower Cafe door had a gap over 1/2 inch, compromising smoke resistance. These issues were confirmed by the Director of Plant Operations.
The facility failed to maintain a fire-rated door separating Nursing Care from Assisted Living, compromising fire safety. The door had been modified, resulting in gaps and unauthorized repairs, affecting one of ten smoke compartments. The Director of Plant Operations confirmed these deficiencies.
The facility was found to be non-compliant with NFPA 101 standards as soiled linen was improperly stored on the floor under the sink in the 300 Wing Tub Room, outside a rated room or container. This was confirmed by the Director of Plant Operations.
Failure to Follow Physician Orders for Catheter Care and Oxygen Therapy
Penalty
Summary
The facility failed to follow multiple physician orders for one resident with diagnoses including obstructive and reflex uropathy, urine retention, and atrial fibrillation. Physician orders dated September 5, 2025, directed that Foley catheter care be provided every shift. Review of the resident’s December 2025 and January 2026 MARs showed numerous shifts on which Foley catheter care was not documented as provided, including multiple day and evening shifts across both months. The resident also had physician orders dated October 30, 2025, for continuous oxygen at 2 liters via nasal cannula every shift for shortness of breath, and orders dated September 4, 2025, to keep the head of the bed elevated every shift to prevent shortness of breath while lying flat. Review of the December 2025 and January 2026 MARs revealed that these oxygen and head-of-bed elevation orders were not followed on the same multiple day and evening shifts where Foley care was missed. During an interview on January 8, 2026, at 10:05 a.m., the DON was presented with this information and confirmed that the physician orders had not been followed.
Failure to Follow Physician Orders for Enteral Nutrition and Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. Resident 86, who has medical diagnoses including dysphagia, muscle wasting, and severe protein-calorie malnutrition, was prescribed Jevity 1.5 at 40ml per hour for 20 hours via a Kangaroo pump, totaling 800ml per day. Observations on two separate days revealed that the pump was disconnected and turned off before the prescribed amount was administered. A review of the resident's Medication Administration Record (MAR) for February showed that the resident never received the full prescribed amount of tube feed on any day. The Director of Nursing confirmed that the amounts documented on the MAR did not match the physician's orders. Resident 164, diagnosed with Type II Diabetes Mellitus, had a physician's order for Insulin Aspart to be administered every six hours. However, the insulin was not administered seven times between February 1 and February 18. The MAR indicated that the insulin was held due to blood sugar levels being within limits or other unspecified reasons, but there were no parameters provided for holding the insulin. Additionally, there was no documentation that the physician was notified about the missed doses. The deficiencies were confirmed with the Director of Nursing, who acknowledged the discrepancies between the physician's orders and the care provided. The facility's failure to administer the prescribed treatments as ordered for both residents highlights a significant lapse in following medical directives, which is crucial for maintaining the health and well-being of residents with complex medical needs.
Failure to Ensure Appropriate Use of As-Needed Anti-Anxiety Medications
Penalty
Summary
The facility failed to ensure that appropriate indications and non-pharmacological interventions were provided before administering as-needed anti-anxiety medications for two residents. Resident 3 had a physician's order for Ativan gel to be applied topically for anxiety, both routinely and as needed. However, from November 1 to November 30, 2024, the as-needed Ativan gel was administered seven times without appropriate indication and five times without attempting non-pharmacological interventions. Similarly, Resident 22 had a physician's order for Clonazepam to be administered as needed for anxiety. From January 17 to January 31, 2025, the as-needed Clonazepam was administered nine times without appropriate indication, and non-pharmacological interventions were not attempted before its administration. These deficiencies were confirmed with the Director of Nursing, indicating a failure in the facility's protocol for administering psychotropic medications.
Deficiency in Corridor Door Maintenance
Penalty
Summary
The facility failed to maintain the corridor doors to positively latch and resist the passage of smoke, affecting two of ten smoke compartments. During an observation on February 5, 2025, at 2:10 PM, it was noted that the double doors to the Main Street Cafe, located by the Activity Room door, did not positively latch. This observation was confirmed through an interview with the Director of Plant Operations at the same time. Additionally, another observation on February 5, 2025, at 2:15 PM, revealed that the door to the Sunflower Cafe had a gap on the strike side greater than 1/2 inch, which compromised its ability to resist the passage of smoke. This deficiency was also confirmed in an interview with the Director of Plant Operations at the time of the observation.
Plan Of Correction
K-0363 (E) Corridor- Doors This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure smoke, fire, and corridor doors will operate as per design. 1. The doors by room, the sunflower café, and double doors by main street café have had the doors repaired and now they close, latch, and are gap free as design. 2. Doors throughout the facility were checked to allow for closure; all residents are free from hazards and all systems are operating as designed as of 2/7/2025. 3. Education completed with maintenance staff regarding monitoring doors and rating labels to ensure they close properly on 2/7/2025. 4. Every quarter for a year, the Maintenance Director or designee will check random doors throughout the facility to ensure the doors are fully closed. This information will then be entered on a log and will be presented to the monthly QAPI meeting.
Fire-Rated Door Deficiency in Smoke Compartment
Penalty
Summary
The facility failed to maintain the integrity of a fire-rated door, which is crucial for ensuring safety in the event of a fire. During an observation, it was noted that the corridor fire-rated door, which separates the Nursing Care area from the Assisted Living area at the breezeway end of the 600 Wing, had been improperly modified. The door had been planed on the strike edge, resulting in gaps greater than 1/8 inch, and a hole in the door had been filled with an unauthorized product. These modifications compromised the door's fire-rating capabilities. The Director of Plant Operations confirmed these deficiencies during an interview conducted at the time of the observation. This issue affected one of the ten smoke compartments within the component, indicating a lapse in maintaining the required fire safety standards as per NFPA 101 guidelines.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to have proper fire rated doors separating Nursing and Assisted Buildings. 1. Replacement of the fire-rated door separating six hundred wings from the assisted living building has been ordered. New fire rated latching hardware will be installed as well. Residents are free from hazards. 2. All rated doors have been inspected, and confirmation of latching and free from gaps completed on 2/7/2025. 3. Education is completed with Maintenance staff to confirm proper door operation of doors on 2/7/2025. 4. Every quarter for a year the Maintenance Director or designee review random doors throughout the building for proper operations. This information will then be entered on a log and will be presented to the QAPI meeting.
Improper Storage of Soiled Linen in Facility
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the storage of soiled linen and trash containers. Specifically, the deficiency was observed in two of ten smoke compartments within the facility. On February 5, 2025, at 2:25 PM, soiled linen was found on the floor under the sink in the 300 Wing Tub Room. This observation was confirmed through an interview with the Director of Plant Operations, who acknowledged that the soiled linen was stored outside a rated room or container, which is a violation of the requirement that soiled linen or trash collection receptacles exceeding 32 gallons must be located in a protected space when not attended.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. It is the practice of the facility to ensure no excess of receptacles are utilized. 1. The trash containers exceeding thirty-two gallons that were being utilized to store items have been removed and are no longer utilized in the facility and have been replaced with proper storage containers. The linen under the sink in three hundred wing tubs has been removed as well. 2. Facility wide inspection of any trash containers and under sink storage was completed on 2/7/2025. 3. Education with facility wide staff regarding improper disposal of soiled linen and containers needing to be under 32 gallons in shower and tub rooms, to be completed by 3/21/2025. 4. Weekly random audits to be completed for 12 months by Maintenance Director or designee for compliance. This information will then be entered on a log and will be presented to the QAPI meeting.
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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