Health inspection·December 5, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) and wore the appropriate personal protective equipment (PPE) while providing care for 1 (Resident #25) of 2 residents reviewed for tube feedings. Residents Affected - Few Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 11/14/2024, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy indicated, 2. Initiation of Enhanced Barrier Precautions: included b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g. [exempli gratia, for example] chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted central catheter] lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO [multi-drug resistant organism]. The policy revealed, 3. Implementation of Enhanced Barrier Precautions: included b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. According to the policy, 4. High-contact care activities include: g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters. An admission Record indicated the facility re-admitted Resident #25 on 11/09/2020. According to the admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) following cerebral infarction (stroke) and gastrostomy status (feeding tube). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/23/2024, revealed Resident #25 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident had a feeding tube and received 51% of their total calories and 501 cubic centimeters (cc) of fluid a day through the feeding tube. Resident #25's care plan included a focus area revised 08/03/2024, that indicated the resident required EBP due to having a gastrostomy tube. Interventions directed staff to clean their hands before and when leaving the room; to wear gloves and a gown for device care and when using feeding tubes; (continued on next page) 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 2 Event ID: 555657 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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)