§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 facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement enhanced barrier precautions (EBP) and the use of personal protective equipment (PPE) to prevent the spread of infection for one of 27 sampled residents. (Resident 116)
Findings include:
Review of the facility policy entitled, "Enhanced Barrier Precautions," last reviewed May 6, 2026, revealed that EBP were to be used with any "high-risk resident" with an indwelling device during "high contact care activities" including, catheter care, bathing, dressing, and changing linens. EBP included the use of PPE such as protective gowns and gloves during high-risk activities.
Clinical record review revealed that Resident 116 had diagnoses that included Parkinson's Disease, stroke, and neuromuscular dysfunction of the bladder (urinary retention), requiring an indwelling catheter. The Minimum Data Set assessment dated May 11, 2026, revealed that Resident 116 had an indwelling catheter, and was dependent on staff for catheter care, bathing and dressing. On July 7, 2026, at 11:29 a.m., a nurse aide (NA 1) was observed in Resident 116's room. NA 1 provided care to Resident 116, got him dressed for the day, and changed soiled linens without wearing a gown.
On July 8, 2026, at 1:32 p.m., the Director of Nursing confirmed that NA 1 should have used appropriate PPE during Resident 116's care.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 08/06/2026
1. Resident 116 experienced no negative effect. NA 1 was educated on enhanced barrier precautions and the importance of wearing PPE during high-contact activities.
2. All residents on Enhanced Barrier Precautions have the potential to be affected.
3. Licensed Nursing staff and certified nursing assistants were educated by the Infection Preventionist/Staff Development Coordinator regarding Enhanced Barrier Precautions policy and the importance of wearing PPE during high contact activities.
4. Director of Nursing, or designee will conduct random observational audits of staff providing care to residents requiring Enhanced Barrier Precautions to assure PPE is worn during high contact activities. Audits will be done weekly x 4, then monthly times 3, then quarterly x 2 or until sustained compliance is achieved. Findings will be reported to QAPI committee.
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