§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 observations, Review of facility policies and clinical records. Interview with staff. It was determined that the facility failed to ensure an effective infection control program. related to tube feeding and oxygen administration. Three of 12 residents reviewed. (Resident R1, R8 and R3).
Findings Include:
Review of facility policy, titled " OXYGEN ADMINISTRATION AND CARE OF EQUIPMENT", dated January 1, 20218, revealed, " Change cannula bi-weekly and as needed. Date and time should be on bottle and cannula. Oxygen tubing should be placed in a plastic bag attached to the concentrator when not in use."
Observation of the facility nurses' station on February 4, 2026, at 12:15 p.m., with Employee E3, Infection Control Nurse, Employee E3, revealed that the tube feeding stand for Resident R1 was inside the nurse's station medication room. It was revealed that the stand had stains of dried tube feeding formula indicating the stand and the machine was not cleaned or disinfected prior to storing in the nurse's station. Employee E3 stated staff removed the stand and the pump after the administration and confirmed that it was not cleaned or disinfected. Employee E3 stated staff should disinfect or clean the pump and stand when removed out of resident room to prevent cross-contamination.
Observation of Resident R8 on February 3, 2026, at 11:30 a.m. and on February 4, 2026, at 12:30 p.m revealed Resident R8 had an oxygen concentrator in his room, the oxygen tubing was undated and was not bagged.
Observation of Resident R3 on February 3, 2026, at 11:35 a.m. revealed Resident R3 had an oxygen concentrator in his room, the oxygen tubing was undated and was not bagged. There was a nebulizer tubing on the nightstand which was not bagged.
Observation of Resident R3 on February 4, 2026, at 12:35 p.m. revealed Resident R3 had an oxygen concentrator in his room, the oxygen tubing was not bagged. There was a nebulizer tubing on the nightstand which was not bagged.
Employee E3 confirmed the above finding on on February 4, 2026, at 12:15 p.m., during a tour of the nursing unit.
28 Pa. Code 211.12(d)(1)(2)(3)(5)Nursing service
| | Plan of Correction - To be completed: 03/02/2026
It is the policy of Waverly Heights to 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.
Facility immediately placed all oxygen tubing for R1, R8, R3 and all residents on oxygen were checked and placed in bags and labeled with date on 2/4/2026.
R1 tube feeding stand that was stored in the med room was cleaned immediately and disinfected per protocol on 2/4/2026.
Facility policy, titled "Oxygen and Administration and Care of Equipment" was updated on 2/11/2026 Nursing staff were in-serviced on storage of oxygen tubing and ensuring all medical equipment is clean and disinfected after each use.
Regular audits will be conducted by Director of Nursing, or designee, to ensure all oxygen tubing is stored in a plastic bag, labeled with date and all medical equipment i.e. tube feeding stand is sanitized and cleaned after each use. Audits will be completed weekly for 4 weeks and then monthly thereafter.
These audits will be reviewed at the quarterly QAPI meetings.
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