Bel Aire Center

Inspectors wroteBased on interview and record review, the facility failed to provide education and ensure nursing competencies regarding the application and monitoring of an Unna boot (compression dressing impregnated with healing agents) for 3 of 3 nursing staff. As a result, Resident #1 developed a large necrotic ulcer on his/her foot requiring admission to the hospital which later resulted in a below the knee amputation.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were updated with a new intervention for 1 of 3 residents sampled (Resident #1). As a result, the resident sustained a necrotic ulcer on his/her right foot related to improper application of an Unna boot (compression dressing impregnated with healing agents) requiring admission to the hospital which later resulted in a below the knee amputation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control policies regarding Enhanced Barrier Precautions (EBP; staff use of gown and gloves during high contact care) for 1 of 1 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained as free from accidents as possible related to falls for 3 of 3 sampled residents (Residents #1, #2, and #3) by failing to ensure assistive devices functioned properly, provide adequate supervision, and create and implement effective, timely interventions that would reduce the likelihood of future falls. As a result, Resident #1 suffered a fall that resulted in pain, a fractured nose, a left humerus (upper arm bone) fracture, and rib fractures. This is a repeat deficiency for this facility, with the violations cited during the previous recertification survey dated 7/17/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was free from physical restraints for 1 of 1 applicable resident (Resident #2) related to a seat belt that the resident was unable to remove on their own.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) of three sampled residents was free from significant medication errors which resulted in a resident developing DVT [Deep Vein Thrombosis] and being transferred to the emergency department.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate interventions to prevent accidents for 2 residents [Residents #25 & #35] of 4 sampled residents.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to provide sufficient nursing staff to maintain the highest practical physical, mental, and psychosocial wellbeing of the facility's residents.

Inspectors wroteBased upon observation and interview, the facility failed to ensure expired medications were stored or disposed of properly, and medications were secured.

Inspectors wroteBased on record review and interview, the facility failed to obtain required consents and maintain accurate records regarding influenza and pneumococcal vaccines for 3 out of 5 residents [Residents #2, 15, 50].

Inspectors wroteBased on observation and interview, the facility failed to ensure one resident [Resident #4] of 3 sampled residents was treated with respect and dignity regarding personal medical equipment.

Inspectors wroteBased on interview and record review, the facility failed to treat and manage 1 of 2 sampled resident's pain [Resident #40] per physician orders and plan of care.

Inspectors wroteBased on record review and interview the facility failed to have a consent form for 1 [Resident 42] out of 5 residents for Covid-19 vaccination.

Inspectors wroteBased upon interview and record review, the facility failed to report allegations of abuse to the appropriate agencies and responsible parties in the required timeframes for 1 resident [Resident #1] of 4 sampled residents.

Inspectors wroteBased upon interview and record review, in response to allegations of abuse the facility failed to Immediately investigate the allegations and to prevent further potential abuse for 1 resident [Resident #1] of 4 sampled residents.

Inspectors wroteBased upon interview and record review, the facility failed to implement care plan interventions regarding medications and physician orders for 1 resident [Res.#1] of 4 sampled residents.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to Enhanced Barrier Precautions (EBP) and residents identified as at risk.

Inspectors wroteBased on interview and record review the facility failed to provide activities of daily living care based on resident preference for 3 of 21 residents sampled (Residents #43, #209, and #15).

Inspectors wroteBased upon observation, interview, and record review, the facility failed to review and revise resident Care Plans related to falls for 3 Residents (Res.# 36, #37, and #47) of 28 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization for 2 applicable residents (Residents #26 and #11).

Inspectors wroteBased upon interview and record review, the facility failed to provide sufficient nursing staff related to resident care and treatment for Res.#20, #36, #8, #51and #209 of 28 sampled residents.

Inspectors wroteBased on interview and record review the facility failed to ensure that 4 of 5 sampled licensed nursing assistants (LNAs) and 4 of 5 nurses were assessed for competency in the skills required to care for the resident needs based on resident care plans.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who use psychotropic drugs are accurately monitored for behaviors and/or side effects for 5 of 5 sampled residents (Residents #3, #26, #36, #6 and #47).

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure that an allegation of staff to resident abuse was reported to the State Licensing Agency as required.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care for 2 of 9 residents in the sample (Resident #49 and Resident #3).

Inspectors wroteBased on record review and interview, the facility failed to provide treatment and care to an existing non-pressure-related injury in accordance with professional standards of practice and the person-centered care plan consistent with the facility policy for 1 of 6 residents (Resident # 11). Findings Include: Per record review, Resident #11 was admitted to the facility on [DATE] with the following diagnoses: Acute osteomyelitis (infection in the bone) of left ankle and foot, acquired absence of left great toe (amputation), Type 2 Diabetes, and peripheral artery disease (PAD), (the narrowing or blockage of the vessels that carry blood from the heart to the legs.) Per record review, a care plan entry was dated 3/28/24 with an intervention of weekly wound assessment to include measurements and description of wound status. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, and the comprehensive person-centered care plan for 1 of 21 sampled residents (Resident #3).