Belle View Estates Rehabilitation and Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 1 puree machine was maintained in a clean condition to prevent the potential contamination of residents' food which had the potential to affect 6 residents who received puree meals from the kitchen; food items prepared for meals were covered or sealed to prevent potential cross contamination or food borne illness, and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 64 residents who received meals from the kitchen total census of 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 2 (Residents #111 and #161) of 2 sampled residents who required assistance with nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ' s orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for 3 (Residents #9, #33, and #45) of 4 residents observed during the medication passes

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the refrigerated narcotic medications in the medication storage room for the 200 and 400 Halls were stored in a permanently affixed compartment in 1 of 2 medication storage rooms to prevent the potential of misappropriation of resident property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clean linens were transported in a manner to prevent the potential for contamination; failed to ensure staff performed proper hand sanitation to decrease the potential for cross contamination and to provide a safe and sanitary environment; failed to ensure an ice scoop was not placed inside of an ice cart while passing ice to residents on the 300 hall These failed practices had the potential to affect 67 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a catheter tubing was secured to prevent complications from trauma for 1 (Resident #57) of 1 sampled resident who had a catheter.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Antibiotic Stewardship Program was consistently implemented, as evidenced by an antibiotic was prescribed for a diagnosis of Abnormal UA (urinalysis) without confirmation of a culture report, to decrease the potential for harm caused by unnecessary antibiotic use and to decrease the potential for resistance for 1 (Resident #41) of 1 (Resident #41) sampled residents who were prescribed an antibiotic without confirmation of a urinary tract infection (UTI) as documented on a list provided by the Administrator on 3/14/24.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly secure a resident wheelchair in the facility van prior to transport, which resulted in a fall with injury to the head and spinal vertebrae requiring emergency room evaluation for 1 (Resident #1) of three (Resident #1, #2 and #3) sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure leftover food items were maintained to promote food quality and/ or prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; failed to ensure foods stored in the kitchen areas, freezer and refrigerator were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; failed to ensure expired food items were promptly removed/discarded on or before the expiration or use by dates; failed to ensure dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; and failed to ensure 1 of 1 ice machine was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodations of needs by not having the call light within reach for 2 Residents (R #34 and R #108) that required assistance with Activity of Daily Living (ADLs) and required the call light to request assistance.

Inspectors wroteBased on observation, record review, and interview the facility failed to promote and facilitate resident self-determination through support of resident choices for 2 residents (R #14 and R #108) who chose not to get up before 5:00 am daily.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure planned fall prevention interventions were consistently implemented to promote safety and prevent falls for 1 (Resident #54) of 8 (Residents R #21, R #24, R #38, R #52, R #53, R #54, R #55, and R #208) sampled residents who had a history of falls in the past 120 days. This failed practice had the potential to affect 14 residents who had falls in the past 120 days, according to a list provided by the Assistant Director of Nursing (ADON) on 1/25/23 at 2:15PM.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Activity of Daily Living (ADL)s were carried out to promote good health and wellbeing for one (Resident #25) of 19 (R #2, R #9, R #10, R #12, R #14, R #15, R #21 R, #24, R #25, R #34, R #38, R #39, R #40, R #52, R #53, R #54, R #108, R #109, R #208) sampled residents. The failed practice had the potential to affect all 59 residents who required assistance with ADLs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure planned fall prevention interventions were consistently implemented to promote safety and prevent falls for 1 (Resident #54) of 8 (Residents #21, #24, #38, #52, #53, #54, #55 and #208) sampled residents who had a history of falls in the past 120 days. This failed practice had the potential to affect 14 residents who had falls in the past 120 days, according to a list provided by the Assistant Director of Nursing (ADON) on 1/25/23 at 2:15 p.m.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory equipment was properly store and dated to prevent contamination for 1 (Resident #34) of 4 (Resident #15, R #34, R #108, and R #208) sampled residents. This practice had the potential to affect 7 resident who received nebulizer treatments. 1. Resident #34 had diagnoses of Hemiplegia, Parkinson's Disease and Active COVID-19 infection. The Quarterly MDS [Minimum Data Set] with an ARD [Assessment Reference Date] of 10/20/22 documented the resident scored a 15 on a BIMS [Brief Interview for Mental Status] (13-15 indicates cognitively intact), required physical assistance of one-person for bed mobility. a. Resident #34's Physician's Orders dated 1/22/23 documented, .Droplet Isolation Precautions for COVID-19 every shift for 10 Days related to COVID-19 . [...]

Inspectors wroteBased on observation and interview the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, as documented on the list provided by the Dietary Supervisor on 1/23/2023 at 10:57 AM.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's wishes regarding Cardiopulmonary Resuscitation (CPR) was accurately conveyed in the resident's chart for 1 (Resident R #55) who had a document titled, Do Not Resuscitated (DNR) signed by the Physician present in the Electronic Medical Chart under the Documents tab.