§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 a review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection for seven of seven residents (Resident R1, R2, R3, R4, R5, R6, and R7) and two of three employees (Employee E1 and E2).
Findings include:
Review of the Pennsylvania Department of Health "Respiratory Virus Outbreak Toolkit" dated 11/24/25, indicated:
-Respiratory Virus Outbreaks: "All respiratory virus outbreaks are reportable to PA DOH BOE (Pennsylvania Department of Health Bureau of Epidemiology) within 24 hours.
-LTCF (long-term care facility) Outbreak Definitions: (1) confirmed case of respiratory virus and (1) acute respiratory illness symptomatic resident -or- (2) confirmed cases of respiratory virus.
-Outbreak Checklist: "Implement daily active surveillance for respiratory illness among residents and healthcare personnel (HCP) using the case line list. Include anyone with symptoms AND/OR positive tests."
-Staffing: "Restrict from work until at least 3 days have passed since symptom onset (or since first positive test if asymptomatic) and at least 24 hours have passed with no fever (without the use of fever reducing medicines), symptoms are improving, and HCP feel well enough to return to work. The first possible day for HCP to return to work is day 4." "Day 0 is the first day that symptoms develop. If no symptoms are experienced, the first day of positive test should be used as day 0."
Review of the facility policy, "Infection Control Nursing" updated 12/20/25, indicated, "Any HCP (healthcare personnel) who develops a fever or symptoms consisted with COVID-19 should immediately direct supervisor, and be restricted from work until at least 3 days has passed from onset of symptoms or positive COVID-19 test and 24 hours without fever. HCP is to wear a mask a minimum of 7 days after onset. If symptoms continue including fever, HCP should continue to be restricted from work until afebrile (as per PA DOH Respiratory Virus Outbreak Toolkit 11/2025)."
Review of a facility provided list indicated:
-Resident R1 tested positive for Covid-19 on 12/29/25.
-Resident R2 tested positive for Covid-19 on 01/02/26.
-Resident R3 tested positive for Covid-19 on 01/03/26.
-Resident R4 tested positive for Covid-19 on 01/03/26.
-Resident R5 tested positive for Covid-19 on 01/04/26.
-Resident R6 tested positive for Covid-19 on 01/07/26.
-Resident R7 tested positive for Covid-19 on 01/10/26.
Review of information submitted to the Pennsylvania Department of Health failed to include reporting of the facility outbreak of Covid-19 on 1/3/26 (two confirmed residents within 72 hours).
Review of a facility provided list indicated:
Registered Nurse (RN) Employee E1 tested positive for Covid-19 on 1/3/26 (Day 0).
Review of facility provided staffing documents revealed RN Employee E1 returned to work on 1/5/26 (Day 2). RN Employee E1's return to work date per PA DOH guideline was 1/7/26.
RN Employee E2 tested positive for Covid-19 on 1/12/26 (Day 0).
Review of facility provided staffing documents revealed RN Employee E2 returned to work on 1/15/26 (Day 3). RN Employee E2's return to work date per PA DOH guideline was 1/16/26.
During an interview on 01/29/26, at approximately 10:00 a.m. the Director of Nursing confirmed the facility did not maintain a line list to with information regarding positive test dates, symptoms, and length of precautions, confirmed that the facility did not report the Covid-19 outbreak beginning on 1/2/26, and confirmed RN Employees E1 and E2 returned to work prior to the return to work date specified by PA DOH guideline.
During an interview on 1/29/26, at approximately 10:15 a.m. the Director of Nursing confirmed the facility failed to ensure an environment free from the potential spread of infection for seven of seven residents (Resident R1, R2, R3, R4, R5, R6, and R7) and two of three employees.
28 Pa. code: 201.14(a) Responsibility of Licensee.
28 Pa. Code: 201.18 (b)(1)(e)(1) Management.
28 Pa. Code: 211.10(a)(d) Resident Care Policies.
28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing Services.
| | Plan of Correction - To be completed: 02/20/2026
- What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
This respiratory virus outbreak of December 29, 2025, through January 10, 2026 has been reported to the Pennsylvania Department of Health Bureau of Epidemiology.
Employee who tested positive with Covid 19, returned to work after meeting the PA DOH guideline.
- How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
There have been no additional unreported outbreaks that could affect other residents.
No additional employees were tested positively, with Covid 19.
- What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
The Director of Nursing and Assistant Director of Nursing have been educated regarding PA DOH BOE virus outbreaks definition and reporting guidelines.
The director of Nursing and Assistant Director of Nursing have been educated regarding restrictions from work for employees who tested positive with Covid 19.
- How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established?
1. A "Respiratory Virus Outbreak Reporting Log" will be established by the Administrator, in order to track and report occurrences of respiratory virus outbreaks. The Log will be completed by DON or ADON for every confirmed instance of Respiratory Virus Infection among residents. Once two or more residents have been added to the log for every new instance of Covid 19, the Outbreak will be identified and reported to PA DOH BOE by DON or ADON.
2. A "Covid 19 Return to Work Log" will be established by the Administrator, for a proper identification of the work restriction periods for staff with new onset of Covid 19.
Upon positive Covid 19 test, the employee's name will be added to the log and the earliest possible return to workday will be identified in accordance with the DOH guidelines. This Log will be maintained by the HR manager with collaboration and advise of DON or ADON.
The "Respiratory Virus Outbreak Reporting Log" and the " Covid 19 Return to Work Log" will be reviewed by Administrator for each outbreak and on every quarterly meeting of the QAPI committee.
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