A new report from the Department of Health and Human Services Office of Inspector General (OIG) has found that nearly one-third of skilled nursing facilities surveyed in 2025 had significant infection prevention and control deficiencies. The findings, based on a sample of 800 facilities across 40 states, have reignited debate over the adequacy of federal survey processes and the lingering impact of the COVID-19 pandemic on facility operations.
Key Findings
The OIG report identifies three primary areas of concern. First, 30% of surveyed facilities failed to maintain adequate hand hygiene protocols during observed care interactions. Surveyors documented instances of staff moving between residents without performing hand hygiene in 242 of 800 facilities.
Second, 22% of facilities lacked current, facility-specific infection prevention and control plans (IPCPs) that addressed the full range of threats, including seasonal respiratory viruses, antibiotic-resistant organisms, and gastrointestinal outbreaks. Many plans had not been updated since the end of the federal COVID-19 Public Health Emergency in May 2023.
Third, 18% of facilities had not designated a qualified infection preventionist (IP) with adequate training and dedicated time for infection control activities, as required by CMS regulations. In many cases, the IP role was assigned as an additional duty to an already overburdened director of nursing.
Recommendations
The OIG has made four formal recommendations to CMS: increase the frequency of infection control-focused surveys, develop standardized infection control training modules for surveyors, require facilities to submit annual IPCP updates as a condition of participation, and establish a public reporting mechanism for infection control deficiency trends.
CMS has concurred with all four recommendations and indicated that implementation planning is underway, though no specific timeline has been provided.
Industry Response
The American Health Care Association acknowledged the findings but cautioned against a punitive approach. “Many of the facilities flagged in this report are doing their best with limited resources,” an AHCA spokesperson said. “We need investment in training and staffing, not just more citations.”
Patient advocacy groups, by contrast, have seized on the report as evidence that voluntary compliance is insufficient. The Long Term Care Community Coalition called for mandatory annual infection control audits by independent assessors and publication of results on CMS’s Care Compare website.
What Operators Should Do
Regardless of where the policy debate lands, facilities should take immediate steps to review their infection prevention programs. Priority actions include updating the facility IPCP to reflect current threats, ensuring the designated IP has adequate time and training, implementing regular hand hygiene audits with real-time feedback, and documenting all infection control training activities for survey readiness.