PITTSBURGH, PA - State health inspectors documented serious infection control failures at Burgh Care Center on West Street, including inadequate COVID-19 outbreak management, improper wound care procedures that risked cross-contamination, and the absence of a qualified infection prevention specialist for nearly three months.
Infection Control Failures During Active COVID-19 Outbreak
During the April 2025 inspection, surveyors discovered that Burgh Care Center failed to implement proper COVID-19 monitoring and testing protocols despite having an active outbreak that began in January 2025. The facility's infection preventionist admitted to inspectors, "I am still just learning what to do," having started the role in January 2025 without certification until March 27, 2025.
The facility demonstrated multiple failures in outbreak management. When asked about testing protocols during a COVID outbreak, the infection preventionist could not provide specific testing schedules and incorrectly stated the outbreak period lasted 21 days, when CDC guidelines specify 14 days from the last positive case. The facility failed to maintain required line listings tracking ill residents and staff, a fundamental tool for outbreak management that helps identify transmission patterns and monitor recovery.
Most concerning was the observation of a symptomatic staff member who continued working while ill. A licensed practical nurse was observed coughing during the inspection and stated, "I was up all night coughing, all my joints are aching." The nurse reported informing both human resources and the Director of Nursing about the symptoms but was not instructed to test for COVID-19. This represents a critical breakdown in infection control protocols during an active outbreak.
The facility's COVID-19 testing approach lacked consistency and adherence to national standards. The Director of Nursing could not specify testing days, stating only that testing occurred "twice a week" without a structured schedule. Federal guidelines require systematic testing of all residents and staff during outbreaks, typically every 3-7 days, to quickly identify and isolate new cases.
Cross-Contamination Risks During Wound Care
Inspectors observed alarming infection control breaches during routine wound care that created multiple opportunities for spreading infections between residents. During a dressing change for one resident, a licensed practical nurse placed a garbage bag directly on the resident's bedside table and used a yellow disposable gown as a makeshift clean field by laying it on the dresser.
The nurse removed the soiled wound dressing, disposed of it along with her protective equipment, then washed her hands and put on new gloves but failed to wear any other protective equipment while cleaning the wound. This practice violates fundamental wound care protocols that require maintaining full barrier protection throughout the entire procedure to prevent contamination of the wound site and surrounding environment.
After completing the dressing change, the nurse left the room without cleaning either the bedside table or dresser that had been contaminated during the procedure. These surfaces could harbor infectious organisms that might be transmitted to the resident or others who contact these surfaces. Proper protocol requires thorough disinfection of all surfaces used during wound care procedures.
Medication Administration Contamination Incidents
The inspection revealed concerning practices during medication administration that could facilitate disease transmission between residents. One nurse was observed using a washcloth soaked in hand sanitizer for hand hygiene between residents, keeping the contaminated cloth in the medication cart's side compartment. After handling medications with bare hands and administering eye drops, the nurse reused the same washcloth and returned it to the cart, potentially spreading pathogens to subsequent residents.
Another nurse was observed dropping a medication bottle cap on the floor, picking it up, and placing it back on the bottle without performing hand hygiene before continuing the medication pass. The floor in healthcare facilities harbors numerous pathogens including antibiotic-resistant bacteria. Returning a contaminated cap to a medication bottle creates risk for all residents who receive that medication.
These practices violate CDC guidelines requiring hand hygiene with soap and water or alcohol-based sanitizer between each resident contact. Reusable cloths for hand hygiene and contaminated medication supplies create vectors for transmitting infections throughout the facility.
Absence of Qualified Infection Prevention Leadership
Perhaps most troubling was the facility's failure to maintain a qualified infection preventionist from January through March 2025. Federal regulations require nursing homes to designate qualified individuals responsible for infection prevention programs, with specific training in nursing, medical technology, microbiology, epidemiology, or related fields.
The facility's infection preventionist, who began in January 2025, did not receive certification until March 27, 2025, leaving the facility without qualified infection control leadership for nearly three months. During this period, the facility failed to implement critical infection control programs including antibiotic stewardship monitoring from June 2024 through February 2025.
Antibiotic stewardship programs help prevent antibiotic resistance by monitoring appropriate use of antibiotics. The facility's failure to track antibiotic usage for eight months means they could not identify inappropriate prescribing patterns or emergence of resistant organisms, putting all residents at increased risk for difficult-to-treat infections.
Medical Significance and Health Risks
These violations create serious health risks for nursing home residents, who are particularly vulnerable to infections due to advanced age, chronic medical conditions, and weakened immune systems. COVID-19 has a mortality rate of 10-25% among nursing home residents, making proper outbreak management literally a matter of life and death.
Cross-contamination during wound care can lead to serious wound infections, sepsis, and delayed healing. For diabetic residents or those with compromised circulation, wound infections can result in amputations or death. Contaminated medication administration equipment can spread respiratory viruses, gastrointestinal infections, and antibiotic-resistant bacteria throughout a facility.
The absence of qualified infection prevention leadership creates systemic risks. Without proper surveillance and intervention, outbreaks can spread unchecked, antibiotic-resistant organisms can proliferate, and preventable infections can cause unnecessary suffering and death.
Additional Issues Identified
Inspectors documented several other concerning findings during the survey. The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training for five staff members throughout 2024. QAPI programs are essential for identifying and correcting systemic problems before they harm residents.
Documentation gaps were noted throughout the infection control program. The facility could not produce COVID-19 surveillance records from October 2024 through February 2025, despite this being an active outbreak period. A resident who tested positive for COVID-19 and returned to the facility in January 2025 had no physician order for isolation precautions in their medical record.
The facility's infection control policies, while comprehensive on paper, were not being followed in practice. Policies requiring hand hygiene, proper use of personal protective equipment, and enhanced barrier precautions for high-risk care activities were routinely violated during the inspection.
Industry Standards and Corrective Requirements
Proper infection control in nursing homes requires systematic approaches including staff training, consistent application of standard precautions, robust surveillance systems, and qualified leadership. Facilities must maintain infection preventionists who work on-site and have appropriate training to identify risks, implement evidence-based interventions, and ensure compliance with infection control standards.
The violations at Burgh Care Center affected many residents and created potential for actual harm, though inspectors classified the immediate harm as minimal. The facility must submit a plan of correction addressing each deficiency, retrain staff on infection control procedures, and demonstrate sustained compliance with federal and state regulations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pennwood Nursing and Rehabilitation Center LLC from 2025-04-05 including all violations, facility responses, and corrective action plans.
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