Bellaken Skilled Nursing Center

Inspectors wroteBased on observation, interview, and record review, facility failed to:Maintain a functional resident call light system for four residents (Residents 2, 3, 4, and 5)Maintain complete and accurate maintenance records for seven residents with broken call lights (Residents 1, 2, 3, 4, 5, 12, and 13)Maintain complete and accurate maintenance records for five call light repairs that affected five (Residents 6, 7, 8, 9, 10) out of 61 residents. These failures placed residents at risk of not having a reliable method to request assistance and increased the risk of delayed response to care needs potentially leading to resident falls or other adverse outcomes. During a concurrent observation and interview on 4/14/26 at 2:52 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure had the potential to endanger the health and safety of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and accountable medication handling, and implementation of pharmaceutical services procedures when: 1. Quality control tests for blood glucose meters (a device used to measure and display the amount of sugar [glucose] in your blood) used in the facility were not done consistently. 2. There were no remedial actions taken for quality control test results, that were out of range, for a blood glucose meter used in the facility. 3. Unused or discontinued medications were disposed without signatures of a pharmacist or nurse and one other witness. These failures could contribute to unsafe medication use and practices in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food under safe and sanitary conditions when: 1. Low temperature dishwasher did not reach the proper sanitation level. 2. Dietary staff did not wear hair restraints properly to cover all hair. 3. Dietary staff entered the kitchen did not wash upon entry to the kitchen. 4. Dietary staff dropped food tray on the floor next to sink, picked it up then placed it in the cart intended to deliver food to residents. These failed practices had the potential to place residents at risk for developing foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection prevention and control program when: 1. One of 18 sampled residents (Resident 6) had a urinary catheter drainage bag (a device used to empty the bladder and collect urine) that touched the floor. 2. Soiled towels in the laundry room were not stored in a covered, soiled laundry hamper or container. 3. Laundry room daily task checklists were not done by staff. 4. Manufacturer's instructions for use (MIFU) was not followed for cleaning and disinfection of blood glucose meters (a device used to measure and display the amount of sugar [glucose] in your blood) used in the facility. 5. A single-patient use blood glucose meter was used on three patients (Resident 21, Resident 38 and Resident 47) in nursing station 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal immunizations for three of five sampled residents (Resident 61, Resident 60, and Resident 9) when the residents did not receive the pneumococcal immunization after it was offered. This failure had the potential to not protect the residents against serious illnesses like pneumonia (lung infection).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician's order for oxygen (O2) administration for two of three sampled residents (Resident 9 and Resident 215), when Resident 9 and Resident 215's O2 flow rate was not set a the specific order rate. This deficient practice may result in ineffective oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication room (a locked room used to store medications and supplies), one out of two medication carts (a mobile cart that stored medication and supplies for immediate use) and one treatment cart when: 1. An opened, used, multi-dose vial of influenza vaccine was not removed from the medication refrigerator after 28 days of first use. 2. Expired (outdated) medications and items were stored and not removed in the medication room, treatment cart and medication cart. These failed practices could contribute to unsafe medication use in the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer and provide COVID-19 immunizations for two of five sampled residents (Resident 61 and Resident 60). This failure could result in not protecting the residents against potential severe illness or post COVID-19 conditions that can be associated with COVID-19 infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 17 sampled residents (Residents 217, 50, and 10) had a call light within reach. This deficient practice had the potential for residents to have unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent from the residents and or their Family Representatives (FR) prior to use of bed side rails for four of four sampled residents (Resident 64, 41, 25 and 30). This failure resulted in Resident 64's Family Representative (FR 1) to be unaware of risks and benefits of bed side rails. This failure had the potential for Resident 41, 25 and 30 and their FR's to be unaware of risks and benefits of bed side rails use.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed proper infection control standards and transmission-based precautions to prevent the spread of infection during an active COVID-19 (commonly known as Coronavirus; a mild to severe, and an highly infectious respiratory illness) outbreak when the following occurred: 1. The facility did not have enough Personal Protective Equipment (PPE) including gowns and gloves readily available to direct care staff to provide resident care to those who were known/suspected to have been exposed to the COVID-19 virus. The facility had only one isolation cart containing four isolation gowns available for direct care staff to provide care to 15 residents in eight different rooms in the Yellow Zone area (designated area for those residents that were known or supected to be exposed to COVID-19). 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to post Ombudsman Program information and contact information for the State Long-Term Care Ombudsman Program. This deficient practice has the potential to prevent residents from contacting the State Ombudsman for services if needed.

Inspectors wroteBased on interview and record review, the facility failed to inform and give reasonable notice to one (Resident 32) of three sampled residents (or to his Responsible Party) that Resident 32's Medicare services were ending and what his rights were to appeal. This failure resulted in Resident 32 not being able to appeal for an extension of Medicare coverage which had the potential to impact his care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide podiatry services to one of 17 sampled residents (Resident 17) for a period of five (5) months when Resident 17's toenails were observed to be long, thick, and curvy. This failure had the potential for skin injuries/wound development for Resident 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Range of Motion (ROM) exercises were provided according to the physician's order, for one (Resident 50) of four sampled residents reviewed for limited ROM. This failure had the potential to result in a decline in Resident 50's ROM/mobility.

Inspectors wroteBased on interview and record review, the facility failed to provide care consistent with professional standards of practice for one (Resident 21) of two residents that require dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood). for Resident 21, staff did not perform complete assessments before Resident 21 recieved dialysis treatments. This deficient practice resulted in incomplete assessments of Resident 21's dialysis access site (site on a person that attaches to the dialysis machine via soft tubing; important to assess the access site for patency) or of her weights (checking weights help determine if dialysis is working/or how much fluid needs to be removed) and had the potential for any access site or excess fluid concerns not being identified before Resident 21's dialysis treatments began.