§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;
§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.
§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.
§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
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Observations:
Based on policy review, observations, and staff interviews it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, as well as ensure the safe and sanitary handling of soiled linens, for two of three resident areas observed (100 Long Hall and the 200 Back Hall).
Findings Include:
Review of the facility's policy, titled "Infection Prevention and Control," recently reviewed June 2026, read, "The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections." The policy continued, "All personal are trained on infection prevention and control policies and procedures upon hire and periodically thereafter ..."
Review of the facility's policy, titled "Laundry and Bedding, Soiled," also revised June 2026, read, "Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control."
"Handling 1. All used laundry is handled as potentially contaminated by using standard precautions (e.g. gloves and gowns when sorting). 2. Contaminated laundry is bagged or contained at the point of collection."
"Transport 1. Contaminated linen and laundry bags/containers are not held close to the body or squeezed during transport. 2. Linen carts are cleaned and disinfected whenever visibly soiled and according to the established scheduled."
An observation on September 9, 2026, at 10:11 AM, revealed a noticeably soiled washcloth, with brown spots, sitting on the floor in the 100 Long Hall.
At approximately 10:13 AM, Employee 6 (Director of Housekeeping and Laundry) noticed the washcloth and retrieved it from the floor for proper disposal.
During the same observation, at 10:11 AM, Employee 4 (Nurse Aide) was observed exiting Resident 6's room while carrying an armful of linen. Employee 4 was immediately redirected and reentered the room and found bagging for the soiled linens she previously had carried into the hall without any bagging.
An observation on September 9, 2026, at 10:20 AM, on the 200 Back Hall, revealed Employee 5 (Nurse Aide) exiting Resident 3's room with unbagged soiled linen, walking down the hall while holding the items against her uniform.
An interview with the Director of Nursing on September 9, 2026, at 11:43 AM, confirmed that nursing staff should not transport soiled linen without utilizing facility infection control practices and that soiled linens should not be found on the facility floor.
28 Pa. Code 211.12 (d) (1) (2) (5) Nursing services
| | Plan of Correction - To be completed: 10/20/2026
No residents were identified as being affected by the alleged deficient practice. Employee #4 received education and discipline. Employee #5 is contracted and is no longer allowed to schedule shifts at the facility.
Director of Nursing and Nurse Manager conducted a facility-wide audit to identify infection control concerns on September 18, 2026. No issues were identified.
Licensed nurses, nurse aides, and therapy staff will be educated by the Director of Nursing/designee on the facility policy titled "Laundry and Bedding, Soiled."
Audits will be conducted by the Director of Nursing/designee on linen handling. Audits will be conducted twice a week for two (2) weeks, weekly for two (2) weeks, then monthly for two (2) months. Audit results will be forwarded to Quality Assurance Committee for review and recommendation.
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