Health inspection·December 5, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 14 sampled residents. (Resident 19) Findings include: Review of the facility policy entitled, Self-Administration of Medications, last reviewed on November 20, 2025, revealed that residents had the right to self-administer medications if the staff and practitioner determined it was clinically appropriate for residents to do so. Clinical record review revealed that Resident 19 had diagnoses that included chronic obstructive pulmonary disease (COPD) and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated October 10, 2025, revealed that the resident's cognitive ability was intact and that he used oxygen. On October 31, 2025, a consulting specialist physician recommended that Resident 19 start taking an inhaler medication to treat COPD daily and that the patient must have this inhaler in his room to be taken immediately upon awakening. The attending physician noted that he agreed with this recommendation. A review of Resident 19's medication administration record revealed a physician's order dated October 31, 2025, and updated November 14, 2025, directing staff to administer one puff of the inhaler in the morning at 7:00 a.m. There was no indication that Resident 19 was evaluated to self-administer his inhaler medication prior to December 4, 2025. On, December 4, 2025, at 12:05 p.m., Resident 19 was observed sitting in a wheelchair in his room. In an interview at that time, Resident 19 stated that the inhaler medication was not readily available and was locked in the medicine cart. The resident stated that the specialist told him to self-administer it when he awakened. Resident 19 stated that he was very frustrated with the nursing staff for not following the physician's recommendation. In an interview on December 5, 2025, at 12:30 p.m., the Director of Nursing confirmed that the resident was not assessed to self-administer the medication as per the facility policy and the physician's orders prior to December 4, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Residents Affected - Few Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 395574 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belle Terrace 1320 Mill Road Quakertown, PA 18951 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)