§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, observations, and staff interviews, it was determined that the facility failed to implement enhanced barrier precautions for one of four residents with a feeding tube (Resident R2) and for one resident with airborne precautions. (Residents R2 and R3).
Findings include:
Review of the facility policy titled "Enhanced Barrier Precautions," undated, revealed: "To minimize the transmission of germs transferred from residents to staff hands and clothing, staff will wear a gown and gloves when providing care to residents that require significant physical contact and are at high risk of acquiring or spreading multidrug-resistant organisms (MDROs). Enhanced barrier precautions will be applied to: (A) residents with an indwelling medical device, including a central venous catheter, urinary catheter, feeding tube (PEG tube), or tracheostomy/ventilator, regardless of their MDRO status; and (B) residents with a chronic wound, regardless of their MDRO status. Chronic wounds include pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers; they do not include shorter-lasting wounds such as skin breaks or skin tears covered with a dressing."
Review of the facility policy titled "Categories of Transmission-Based Precautions," undated, revealed: "Standard Precautions shall be used when caring for residents at all times, regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. Based on CDC definitions, four types of Transmission-Based Precautions (airborne, droplet, contact, and COVID-19) have been established. In addition to Standard Precautions, implement Airborne Precautions for anyone who is documented or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small-particle residue [5 microns or smaller] of evaporated droplets containing microorganisms that remain suspended in the air and can be widely dispersed by air currents within a room or over long distances). Examples of infections requiring Airborne Precautions include, but are not limited to: measles, varicella (including disseminated zoster), and tuberculosis."
Review of Resident R2's clinical record revealed that the resident was admitted to the facility on January 5, 2026, with diagnosis of anoxic brain damage, persistent vegetative state, chronic obstructive pulmonary disease (airway inflammation and damage), encounter for attention to gastrostomy (feeding tube), dysphagia oropharyngeal phase following cerebral infarction (swallowing disorder that occurs due to brain injury).
A physician's order dated January 17, 2026, for enhanced barrier precautions related to feeding tube.
Observation conducted on March 30, 2026, at 10:20 a.m., revealed nursing aide, Employee E4 providing direct morning care to Resident R2 without wearing personal protective equipment (PPE) such as gown. This observation was confirmed by the unit manager, Employee E3.
On March 30, 2026, at 9:00 a.m., an interview with the Assistant Director of Nursing, Employee E7, revealed that the facility had placed Resident R3 on airborne precautions after Resident R3 tested positive for tuberculosis.
A review of Resident R3's clinical file revealed that the resident was admitted on February 12, 2026. On March 23, 2026, Resident R3 received a positive test result for tuberculosis. A review of the physician's order dated March 23, 2026, revealed: "TBP: Airborne Precautions Tuberculosis (gown, face mask, face shield, and gloves)."
On March 30, 2026, at 10:40 a.m., Licensed Nurse, Employee E5, was observed in contact with Resident R3 in the resident's room wearing only a mask. Unit Manager, Employee E3, confirmed the observation that Licensed Nurse, Employee E5, was not wearing a gown or face shield as required for airborne precautions.
28 Pa. Code 211.10 (d) Resident care policies.
28 Pa. Code 211.12 (d)(5) Nursing services.
28 Pa Code 211.12 (d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 05/20/2026
Residents R2 and R3 were assessed to identify any complications related to Employees E4 and E5 noncompliance with appropriate donning and doffing of personal protective equipment (PPE). Employees E4 and E5 were counseled on wearing PPE when required as well as on transmission-based precautions (TBP) including airborne precautions and enhanced barrier precautions (EBP). Employees E4 and E5 received competency on donning and doffing of PPE.
All residents might be affected by the deficient practice.
Facility employees who provide direct care or anticipate contact with residents on airborne precautions or EBP were educated by the Assistant Director of Nursing (ADON) on donning and doffing of PPE, TBP, including airborne precautions and EBP. Employees received competency on donning and doffing of PPE.
Director of Nursing (DON), Infection Preventionist (IP) or a designee will audit five (5) residents on TBP or EBP by direct observation of staff donning and doffing of PPE. The audit will be competed weekly for twelve (12) weeks. Findings of the audits will be reported to the monthly Quality Assurance and Performance Improvement (QAPI) Committee. The Committee will make any recommendations if needed.
Date of compliance 05/20/2026
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