§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:
Findings:
A review of the facility's policy titled "Surveillance for Infection/Infectious Disease", undated, revealed the facility will conduct daily surveillance for reportable infection or outbreak. The nursing staff must notify the Charge nurse of residents with any of the following conditions: Temperature of 100F or greater; Two episodes or more loose watery stools in a twenty-four-hour period; Inflammation or purulent (pus)drainage at the skin; and Transfer to the hospital because of an infection. The DON (Director of Nursing) of Infection Control (IC) Coordinator must enter the data onto the Weekly Surveillance Line Listing Report (A fundamental row-by-row epidemiological tool used in investigation to organize, track, and analyze key information about individual cases). The DON or the IC Coordinator must collect and tabulate the data to remain aware of trends of an increase in prevalence of infectious conditions.
A review of the facility's policy "Outbreak Plan," undated, revealed that when there is evidence that there may be an outbreak of an emerging infectious disease, but neither the disease nor the source has been identified, an outbreak investigation is to be completed to determine the source of the problem.
A review of the facility's "Outbreak Case-Patient Line List" Report revealed that Resident 1 had more than one LBM (loose bowel movement) in 24 hours on January 30, 2026. The same report revealed that on February 1, 2026, Resident 2, 3, 4, 5, and 6 had more than one LBM in 24 hours. On February 2, 2026, Residents 7 and 8 had more than one LBM in 24 hours, a total of eight residents on the TCU (Transitional Care Unit) had more than one LBM in 24 hours from January 30, 2026, until February 2, 2026.
A review of Resident 9's nursing progress notes dated February 5, 2026, at 1:58 p.m., revealed that residents had two episodes of loose stools.
A review of Resident 9's progress notes dated February 9, 2026, at 1:34 p.m., revealed the resident was noted with two episodes of loose stools.
Review of Resident 10's nursing progress notes dated February 6, 2026, at 1:40 p.m., revealed the resident had multiple episodes of vomiting and was noted to have multiple episodes of loose bowel.
Residents 9 and 10 were not listed on the facility's Outbreak Case- Patient Line List.
An interview with the IC nurse, licensed Employee E3, was conducted on March 2, 2026, at 1:00 p.m. Employee E3 reported that residents showing potential infectious symptoms were communicated to the DON during the daily morning meeting and/or verbal reporting. Employee E3 reported that they only work three times a week. Employee E3 added that the previous DON was the one who initiated the line list for resident showing GI symptoms and then was handed to them on February 2, 2026, to follow up on the residents. Employee E3 was unable to provide an explanation as to why Residents 9 and 10 were not listed on the facility's surveillance report. Employee E3 also confirmed that an investigation was not done to determine the source of the resident's GI symptoms.
The above was conveyed to the Nursing Home Administrator on February 2, 2026, at 2:00 p.m.
The facility failed to ensure appropriate surveillance, monitoring, and tracking were implemented for residents showing GI symptoms.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(3)(5) Nursing service
| | Plan of Correction - To be completed: 03/25/2026
1. Residents #9 and #10 were reviewed by the community to ensure their gastrointestinal (GI) symptoms were appropriately monitored and documented. Residents #9 and #10 were added to the facility's surveillance monitoring for residents exhibiting GI symptoms. The Infection Control (IC) Nurse was immediately reeducated to ensure residents exhibiting symptoms such as loose bowel movements and vomiting are tracked in accordance with the communities Outbreak Plan. Both residents did not have any ill effects from not being tracked on the line listing .
2. An audit was completed on current residents to determine if any residents exhibiting GI symptoms were not included on the facility's Outbreak Case-Patient Line List. Nursing documentation, including nursing progress notes and the surveillance report, were reviewed to identify residents who experienced more than one loose bowel movement in a 24-hour period or other GI symptoms to ensure they were included in monitoring and tracking. No other cases were identified .
3. The Director of Nursing or designee will reeducate the Infection Control Nurse and licensed nursing staff on the Outbreak Plan process to ensure appropriate surveillance, monitoring, and tracking of residents who are exhibiting potential infectious symptoms is being completed.
4. The Infection Control Nurse or designee will conduct a weekly audit X4 and then monthly X2 to review any Outbreak Case-Patient Line List and nursing documentation for residents with GI symptoms or any other potential infectious symptoms to ensure appropriate surveillance and tracking is completed in accordance with the facility's Outbreak Plan. Results of audits will be brought to QAPI for review any recommendations as needed.
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