SENECA, SC - Federal inspectors documented significant deficiencies in infection prevention and control program management at Seneca Health & Rehabilitation Center during a February 2025 survey, identifying systemic gaps in the facility's ability to track, monitor, and respond to infection-related incidents.
Infection Prevention Program Deficiencies
The facility failed to establish and maintain a comprehensive infection prevention and control program (IPCP) as required by federal regulations. Inspectors found the facility lacked proper systems for recording incidents of infections identified through surveillance activities. This fundamental shortfall meant the facility could not adequately track infection patterns, identify emerging threats, or implement timely corrective measures to protect residents.
A functioning IPCP serves as the cornerstone of resident safety in long-term care settings, where vulnerable populations face heightened risks of healthcare-associated infections. Without proper documentation and tracking systems, facilities cannot identify clusters of infections, assess whether interventions are working, or demonstrate compliance with infection control protocols. This gap leaves residents exposed to preventable infections that can lead to serious complications, hospitalizations, or death in elderly populations with compromised immune systems.
The inspection revealed that the facility's infection control program lacked adequate systems for surveillance, tracking, and trending of infections. These components are essential for identifying patterns that might indicate underlying problems with hygiene practices, environmental cleanliness, or staff compliance with infection control procedures. When facilities cannot track infection data over time, they lose the ability to implement evidence-based interventions or measure the effectiveness of corrective actions.
Staffing Gaps in Infection Prevention Leadership
Beyond systemic program deficiencies, inspectors identified critical staffing gaps in the infection preventionist (IP) position. The facility's assessment dated for the survey period indicated plans to employ one infection preventionist, but failed to specify the hours dedicated to this essential role. This omission raised concerns about whether the facility allocated sufficient resources to maintain effective infection prevention oversight.
During an interview on February 13, 2025, facility administrators acknowledged ongoing challenges maintaining qualified staff in the infection preventionist role. "We have hired IPs, and they did not work out," the administrator stated, adding that the Director of Nursing (DON) was filling the gap with proper credentials until a permanent hire could be secured.
While having a credentialed DON provide interim coverage demonstrates some level of contingency planning, this arrangement raises questions about sustainability and workload management. The DON position carries extensive responsibilities for overall nursing operations, quality assurance, and regulatory compliance. Adding infection prevention duties to an already demanding role may compromise the facility's ability to provide the focused attention and specialized expertise that effective infection control requires.
Impact on Resident Safety and Care Quality
The absence of a dedicated, full-time infection preventionist creates multiple risks for residents. Infection prevention requires ongoing surveillance, immediate response to potential outbreaks, staff education, and continuous quality improvement activities. When these responsibilities become secondary to other duties, response times may lag, training may be deferred, and critical warning signs may be missed.
Healthcare-associated infections remain a leading cause of morbidity and mortality in nursing home populations. Urinary tract infections, respiratory infections, skin infections, and gastrointestinal illnesses can spread rapidly in congregate care settings without vigilant monitoring and swift intervention. Elderly residents often present atypical symptoms, making early detection challenging even under optimal circumstances. Without dedicated infection prevention expertise, facilities struggle to implement the proactive surveillance necessary to protect vulnerable residents.
Additional Issues Identified
The inspection documented violations of federal infection control regulations (F881 and F882), both cited at minimal harm levels affecting many residents. The deficiencies centered on the facility's failure to maintain required documentation systems and provide adequate staffing resources for infection prevention activities.
Regulatory Requirements and Industry Standards
Federal regulations require nursing homes to establish and maintain infection prevention and control programs with designated leadership, clear protocols, and comprehensive documentation systems. These programs must include active surveillance, investigation of infection incidents, and implementation of corrective actions when problems are identified. The regulations also mandate that facilities designate qualified infection preventionists with sufficient time and resources to fulfill their responsibilities effectively.
The Centers for Medicare & Medicaid Services emphasizes that infection prevention programs must be proactive rather than reactive, with ongoing monitoring that allows facilities to identify and address problems before residents experience harm. Industry best practices recommend dedicated infection preventionist staffing with protected time for surveillance, education, and quality improvement activities separate from other nursing leadership responsibilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seneca Health & Rehabilitation Center from 2025-02-13 including all violations, facility responses, and corrective action plans.
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