§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 facility policy review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on one of two nursing units observed. (North wing)
Findings include:
Review of the facility policy entitled, "Medication Administration," last reviewed November 7, 2025, revealed that staff was to practice hand hygiene prior to administering medication and was to remove medication from source, taking care not to touch medication with bare hands.
On November 19, 2025, at 8:50 a.m., licensed practical nurse (LPN) 2 was observed preparing medication for Resident 55. LPN 2 used bare hands to remove seven different medications from the resident's medication card and placed them into a medication cup. LPN 2 then touched the computer mouse, opened the medication cart drawers, selected medication bottles, and poured one pill from the bottle into his bare hand and placed it in the medicine cup. LPN 2 did not perform hand hygiene during these tasks and administered the medications to Resident 55.
In an interview on November 19, 2025, at 2:15 p.m., the Director of Nursing confirmed that LPN 2 should not have touched the medications with bare hands.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 12/22/2025
1. LPN2 was educated immediately on hand hygiene practices related to medication administration to prevent the spread of infection.
2. The facility has determined that all residents have the potential to be affected.
3. Licensed Nurses will be educated by Staff Educator/ Designee on hand hygiene practices especially during medication administration to prevent the spread of infection.
4. Random observation of licensed nurses will be done by DON/designee to ensure that they are performing hand hygiene practices during medication administration. Audits will be conducted weekly x 4, monthly x 2 then quarterly or until substantial compliance is achieved. Results of audits will be reviewed by the QAPI committee.
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