§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 documents, and staff interviews, it was determined that the facility failed to ensure that one out of eleven resident room maintained functional running water necessary for hygiene and provision of care. (Room 718)
Findings include:
Review of the Centers for Disease Control and Prevention (CDC), Guideline "for Hand Hygiene in Health-Care Settings, MMWR Recommendations and Reports", Vol. 51, No. RR-16, October 25, 2002. revealed hand hygiene, including washing hands with soap and water, is essential for infection prevention during high-risk patient care activities such as wound care, toileting, tracheostomy care, and feeding tube management. Per CDC guidance, alcohol-based sanitizer alone is not sufficient when hands are visibly soiled or after exposure to bodily fluids, and proper handwashing is required to reduce the risk of infection transmission.
Observations conducted at approximately 9:40 a.m. with the Director of Maintenance, Employee E6, in resident's room 718, it was noted that the sink was not functioning and there was no running water available. The shower was non-functional, with the faucet removed, and although the toilet was operational, the absence of running water in the sink and shower was confirmed. The Director of Maintenance, Employee E6 stated that the water supply to the room had been shut off for approximately two weeks due to a plumbing issue and confirmed that both the sink and shower were inoperable. He further stated that this was the only room on the unit affected by this issue.
Review of facility document review revealed that an outside contracting company evaluated the issue and provided an estimate for repairs to Room 718 dated February 9, 2026. However, the facility did not accept or proceed with the proposed work, and repairs had not been completed as of the date of the survey.
Interview conducted at approximately 2:00 p.m. on March 30, 2026, with the Nursing Home Administrator, employee E1 confirmed awareness of a water issue in Room 718 for approximately two weeks but stated he was unaware that the sink lacked running water. When questioned regarding the repair estimate dated February 8, 2026, approximately seven weeks ago, the Administrator indicated that the facility declined the external estimate and planned to complete the repairs internally; however, no definitive start date or timeline for completion was provided. Employee E1 further stated that hand sanitizer was available in the room as an interim infection control measure and did not identify the lack of running water as an infection control concern. He confirmed that no alternative accommodations had been implemented, despite the facility having available beds (66-bed capacity with a census of 61) and the ability to relocate the resident if necessary.
Interview with Licensed nurse Employee E3 on March 30, 2016, at 1:10 PM, confirmed that the number one priority for infection control in patient care is proper hand hygiene. The Licensed nurse, Employee E3 stated that nursing staff must wash their hands, as it is crucial to patient care. In situations where water is not immediately available, the Employee E3 reported that staff would use hand sanitizer until they are able to wash their hands.
Interview with Respiratory Therapist, Employee E4, on March 30, 2026, at 1:45p.m. revealed that infection prevention is very important, especially in a high-acuity environment. The therapist stated that, in her role, proper hand hygiene is critical to her work.
Interview with Nursing Assistant, Employee E 5 on March 30, 2026, at 1:55 p.m. revealed that staff are educated to wash their hands "all the time," especially before and after providing patient care, in order to prevent infections.
28 Pa. Code 201.14 (a)(g) Responsibility of Licensee
28 Pa. Code 201.18(e) (2.1) Management
28 Pa. Code 204.19 Plumbing, Heating, Ventilation, Air Condition and Electrical
| | Plan of Correction - To be completed: 04/28/2026
1. Repairs to the identified area have been initiated.
2. A facility audit was conducted on all resident rooms to ensure there is a functioning sink.
3. A random monthly audit x 3 will be conducted by the Director of Maintenance to ensure sinks are operational in resident rooms. Staff will be in-serviced on reporting maintenance issues and an education to Maintenance Director on timeliness of repairing any issues noted.
4. Results of the audits will be presented to the QAPI committee to evaluate ongoing audits and the necessity for follow up audits.
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