Health inspection·August 1, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on two of two nursing unit wings. (A Wing, B Wing) Residents Affected - Some Findings include: Review of the facility policy entitled, Transmission Based Precautions, last reviewed March 28, 2024, revealed that transmission based precautions (TBPs) may include contact precautions, droplet precautions, airborne precautions, and enhanced barrier precautions that vary with how restrictive they are in requiring certain personal protective equipment (PPE). If a resident is identified as having a communicable disease, then TBPs are to be initiated. Staff were to post a sign on the door that all personnel and visitors entering the room must first see the nurse to obtain additional information before entering the room as part of maintaining the specific TBP and PPE protocol. Review of the facility policy entitled, COVID-19, last reviewed March 28, 2024, revealed that droplet precautions were to be implemented for residents with a positive Coronavirus disease 2019 (COVID-19) test. Clinical record review revealed that diagnostic testing completed July 28 - 31, and August 1, 2024, resulted in COVID-19 positivity for 13 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14). Observations of the identified positive residents' rooms (20, 21, 22, 27, 34, 36, 41) on August 1, 2024, at 11:30 a.m. and 4:25 p.m., revealed there were no signs posted outside resident rooms and/or on the doors to alert staff, visitors, and other residents of the need see the nurse for additional information to ensure that necessary transmission based precautions and personal protective equipment were implemented upon entering. In an interview on August 1, 2024, at 4:45 p.m., the Administrator confirmed that signs should have been posted on doors of resident rooms when transmission based precautions were required. CFR 483.80 Infection Control Previously cited 12/28/23 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. code 211.12(d)(1)(5) Nursing services. Page 1 of 2 395574 395574 08/01/2024 Belle Terrace 1320 Mill Road Quakertown, PA 18951

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on policy review and staff interview, it was determined that the facility did not have a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control. Residents Affected - Many Findings include: Review of the facility policy entitled, Infection Prevention and Control Plan, last reviewed March 28, 2024, revealed that the IP was to provide oversight for the infection prevention and control program, conduct surveillance of any facility and community associated infections, and serve as a resource to all staff regarding infection prevention and control. In an interview on August 1, 2024, at 1:15 p.m., the Administrator stated the facility did not have a qualified Infection Preventionist. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395574 Page 2 of 2