Belleville Healthcare and Rehabilitation Center

Inspectors wroteBased on record review, observation, and interview, the facility failed to identify, assess, and implement pressure injury prevention interventions for Resident (R) 1, who developed a painful wound to her buttock, in which the hospital identified as an unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer. Staff also failed to assess and document evidence of monitoring the wound once it developed.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to immediately implement dietician recommendations to promote nutritional status during an identified gradual weight loss after admission for Resident (R) 1, who also had wounds. (Refer to F686).

Inspectors wroteThe facility identified a census of 48 residents. The sample included 12 residents, with three residents reviewed for restorative nursing services. Based on observation, interview, and record review, the facility failed to provide restorative nursing services to prevent further decrease in range of motion (ROM) for Resident (R) 40's left hand, which had limited mobility. This deficient practice resulted in actual harm when R40 had a significant decrease in ROM to the left hand, could not mobilize her wheelchair without staff assistance, voiced concern that an orthopedic (pertaining to bones) surgeon would have to rebreak her hand to repair it, and voiced pain in her left hand at all times.

Inspectors wroteThe facility identified a census of 48 residents. The sample included 12 residents. Based on observations, interviews, and record review, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during the day-to-day operations and emergencies.

Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the facility kitchen.

Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide an adequate number of dietary staff to serve the residents, who received their meals in the dining room.

Inspectors wroteThe facility had a census of 48 residents. Based on observation, interview, and record review, the facility failed to cover clean linen and clothing when transporting through the facility to prevent potential contamination, which could lead to infection.

Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility staff failed to treat Resident (R) 16 with dignity at the dining table when Certified Nurse Aide (CNA) P stated, Here is your bib, and placed a clothing protector on R16.

Inspectors wroteThe facility identified a census of 48 residents. The sample included 12 residents, with three residents reviewed for accommodation of needs. Based on record review, observation, and interview, the facility failed to accommodate Resident (R) 31's needs when they failed to ensure R31's walker could safely fit into the bathroom after her admission to the facility. This deficient practice placed R31 at risk for falls as she would leave her walker outside the bathroom door and furniture walk (using the sink for support) in the bathroom to use the toilet and wash her hands.

Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents, with one reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice, as required, to Resident (R) 4 or their representative upon discharge from the facility.

Inspectors wroteThe facility had a census of 48 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to review or revise Resident (R) 5's care plan with new effective interventions after each fall.

Inspectors wroteThe facility identified a census of 48 residents. The sample included 12 residents, with three residents reviewed for Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to ensure Resident (R) 31 was showered/bathed according to her preference, twice a week.

Inspectors wroteThe facility identified a census of 48 residents. The sample included 12 residents, with five residents reviewed for falls, supervision, and safety. Based on record review, observation, and interview, the facility failed to provide a safe environment with appropriate supervision to prevent falls for Resident (R) 46 and R5.

Inspectors wroteThe facility identified a census of 34 residents with three residents reviewed for unintended weight loss. Based on record review, observation, and interview, the facility failed to obtain consistent weights to establish a baseline, failed to identify and respond to progressive weight loss with intervention and increased assistance, and failed to follow the Registered Dietician (RD) recommendations to provide nutritional support for Resident (R)1. Subsequently, R1 had a significant unintended weight loss. This deficient practice also placed R1 at risk for decreased nourishment and delayed wound healing.

Inspectors wroteThe facility identified a census of 34 residents. The facility identified 11 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observation, and interview, the facility failed to ensure staff implemented targeted gown and glove use during the high-contact care of a resident with a wound infection during a dressing change. This deficient practice placed the resident at risk for infectious diseases.

Inspectors wroteThe facility had a census of 58 residents. The sample included three residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 remained free from misappropriation of her property. This placed the resident at risk for ongoing misappropriation and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 58 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure adequate infection control measures for Resident (R) 1 during wound care, when staff did not change her gloves after she cleansed the wound. This placed the resident at risk for continued wound infection and complications.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 47 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for impaired nutrition.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the refrigerator seals were intact and ailed to use sanitation strips for the three-compartment sink. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on record review and interview, the facility lacked evidence the required infection preventionist attended the Quality Assessment and Assurance (QAA) Committee quarterly meetings. This placed the residents who resided in the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to clean the dining tables and chairs to provide a comfortable homelike environment in the dining room. This placed the residents who ate meals in the dining room at risk for an unsanitary, non-homelike environment.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards with staff left one of three medication carts and a treatment cart unsupervised and unlocked by the dining area and failed to secure a wall cabinet in the [NAME] shower room. This placed the seven cognitively impaired, independently mobile residents at risk for preventable accidents or injuries.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the kitchen's plate warmer and prep sink were in safe and operable condition. This placed the residents who received their meals from the kitchen at risk of receiving cold food and the inoperable prep sink created the risk for food borne illness.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to treat two unsampled residents with dignity when staff administered Resident (R) 21's Flonase (allergy medication) nasal spray and R26's dorzolamide timolol (medication used to reduce pressure in the eye) eye drops at the dining room. This placed the residents at risk for an undignified experience.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to handle soiled linen in a sanitary manner to prevent the development and transmission of communicable diseases and infections. This placed the affected resident at risk for infection.

Inspectors wroteThe facility had a census of 39 residents. Based on observation, record review, and interview the facility failed to provide a backflow device (prevent unwanted flow of water in the reverse direction) or a two-inch air gap for the drainage system of the kitchen ice machine, used by the 39 residents who resided in the facility. This placed the affected residents at risk to receive contaminated ice. Findings Included: - On 09/21/22 at 10:59 AM, observation revealed a plastic flex-hose drain device extended from the back of the ice machine, inserted into a rigid plastic drainpipe that extended along the floor and inserted into a floor drain under the dishwasher. Continued observation revealed the ice machine drainage system had no backflow device or two-inch air gap at the rigid plastic drainpipe or floor drain. [...]

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to monitor and adhere to cleaning and disinfecting shared equipment which consisted of a digital thermometer, placing the residents at risk for infection.

Inspectors wroteThe facility had a census of 39 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to place a stop date on an as needed (prn) psychotropic (medication used to treat mental health disorders) medication for Resident (R) 27. This placed the resident at risk for unnecessary medications and related complications.

Inspectors wroteThe facility had a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interview, facility staff failed to place an open date on Resident (R) 19's Levemir (long acting insulin-a medication that works by lowering levels of glucose (sugar) in the blood) flex pen (device used to inject insulin). This placed the resident at risk for receiving an expired and ineffective dose of insulin.