Health inspection·September 3, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to Transmission Based Precautions for two of two residents reviewed (Residents R1and R2) and an Infection Preventionist.Findings include:Review of facility policy, Infection Prevention and Control Program revised in July 2022, revealed that it is the community's policy to 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 disease and infection in accordance with Centers for Disease Control and Prevention (CDC) and the Association of Professionals in Infection Control and Epidemiology (APIC). Further review of policy revealed that The Skilled Nursing Administrator (SNA)/ Director of Nursing Services (DNS) designates a Registered Nurse as the Infection Preventionist (IP). The IP will: A. Be qualified by education, training, experience or certification B. work at least part-time at the facility; and C. have completed specialized training in infection prevention and control, D. be a member of the community's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis. The infection preventionist (IP) evaluates the infection prevention and control program to validate required components with include. A. Fundamental Principles of Infection Control B. Infection Control Program and Infrastructure C. Team member and Resident Safety D. Surveillance and Disease Reporting E. Standard Precautions F. Transmission Based Precautions G. Resident Suite Assignment H. Environmental Cleaning I Safe Injection Practices and Point of Care Testing J. Medication Storage and Handling K. Antibiotic Stewardship program.Interview with Director of Nursing, Employee E1 on September 3, 2025 at 9:05am revealed No infection preventionist in the building, someone is hired however there is not one currently. Interview with Nursing Home Administrator, Employee E2 on September 3, 2025 at 9:45am revealed Facility uses a Regional Registered Nurse, Employee E4, as their Infection Preventionist and she comes to facility a couple times a month. Review of Facility Assessment revealed Frequency relative to Benchmark is High related to infections including, Multidrug-resistant organism, Pneumonia, Septicemia, Urinary Tract Infection, Viral Hepatitis, and Wound Infection. Review of meeting notes for QAPI (Quality Assurance Performance Improvement Plan), no documented evidence of Employee E4, Infection Preventionist in attendance for meetings dated August 27, 2025. Interview with Director of Nursing, Employee E1, on September 3, 2025 at 1:30pm confirmed the Infection Preventionist was not in attendance for the QAPI meetings dated August 27, 2025. Review of facility's documentation revealed the last time the Infection Preventionist, Employee E4 was present at the facility was August 7, 2025. Review of Resident R1's clinical record revealed that resident was admitted on [DATE], with the diagnosis of Obstructive Uropathy (obstruction of urine flow). Review of Resident R1's care plan, date-initiated August 5, 2025, revealed Enhanced Barrier Precautions needed related to Suprapubic Catheter. Review of Resident R2's clinical record revealed that Residents Affected - Few Page 1 of 2 395801 395801 09/03/2025 Quadrangle 3300 Darby Road Haverford, PA 19041

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was admitted on [DATE], with diagnoses of Urinary Tract infection.Review of Resident R2's physician orders, dated August 22, 2025, revealed Enhanced Barrier Precautions.Review of Resident R2's care plan, date-initiated August 26, 2025, revealed The resident has potential for impairment in skin integrity, intervention initiated Enhanced Barrier Precautions. Observations conducted on September 3, 2025 at 11:00am, revealed signage for Enhanced Barrier Precautions on the room doors of Resident R1 and Resident R2. Further observation revealed that the isolation supply bin in front of room did not contain necessary isolation equipment including isolation gowns or gloves. Interview with Employee E3, Registered Nurse on September 3, 2025 at 11:05am confirmed findings of isolation supply bin in front of room did not contain necessary isolation equipment including isolation gowns or gloves 28 Pa Code 201.14(a) Responsibility of licensee28 Pa Code 201.18(d) Management 395801 Page 2 of 2