§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 upon clinical record review, facility observation, review of facility policies, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one resident (Resident #13) out of 16 residents reviewed.
Review of facility policy Enhanced Barrier Precautions, last reviewed April 23, 2025, states "Enhanced Barrier Precautions will be used for those residents with chronic wounds."
Review of Resident #13's wound assessment report dated May 28, 2026, finds that resident has a neuropathic ulcer (a chronic, slow healing, open sore or wound caused by nerve damage and poor circulation) on the left medial first metatarsophalangeal base (where the first toe connects to the long foot bone).
Review of Resident #13's orders does not find an order for Enhanced Barrier Precautions (an infection control strategy used to prevent the spread of multi-drug-resistant organisms).
Observation at Resident #13's room on June 2, 2026, at 10:02 a.m., June 3, 2026, at 1:15 p.m., and June 4, 2026, at 9:20 a.m., does not find Personal Protective Equipment or signage indicating Enhanced Barrier Precautions
Interview with the Nursing Home Administrator and Director of Nursing on June 4, 2026, at 11:30 a.m. confirms that Resident #13 is being treated for a chronic diabetic ulcer on the resident's left foot and the resident is not on Enhanced Barrier Precautions.
An interview on June 4, 2026, at 12:00 p.m. with the Nursing Home Administrator confirms that the facility failed to place Resident #13 on Enhanced Barrier Precautions.
28 Pa Code 201.18(b)(1)(3) Management
28 Pa Code 207.2(a) Administrator's responsibility
28 Pa. Code 211.10(c) Resident care policies
28 Pa Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 07/17/2026
Enhanced Barrier Precautions were put into place for resident #13 on 6/4/2026.
Director of Nursing/designee will complete a random audit of residents with active wounds to ensure that Enhanced Barrier Precautions are implemented per facility policy.
Facility will review and revise Enhanced Barrier Precautions Policy as indicated. Licensed nursing staff will be re-educated on the Enhanced Barrier Precautions Policy and implementing Enhanced Barrier Precautions.
The corrective action will be monitored through auditing weekly skin and wound notes to identify residents that are being treated for chronic wounds. This will be audited weekly for 4 weeks and then monthly for 2 months. If any issues are identified during the audit, they will be corrected, and nursing staff will be re-educated. Results of audits will be reported to the Quality Assurance Improvement Committee.
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