Belmont Bay Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to perform a transfer with a mechanical lift per the manufacturer's recommendation for one of three residents in the survey sample, Resident #1 (R1).

Inspectors wrote3. For Resident #45 (R45), the facility staff failed to assess the resident for safe independent smoking. Resident #45 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (1) and diabetes mellitus (2). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 5/13/2024, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of the MDS documented no tobacco use. The comprehensive care plan documented in part, The resident is a smoker. Resident educated on facilities nonsmoking policy. Date Initiated: 07/22/2022. Under Interventions it documented in part, .Instruct resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 07/22/2022 . [...]

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to follow the prescribed menu in one of one kitchen.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to serve palatable food in one of one kitchen.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to serve food at the consistency ordered by the physician for one of 50 residents in the survey sample, Resident #26.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to serve food according to a resident's preference for four of 50 residents in the survey sample, Residents #4, #22, #66, and #68

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store and serve food in a sanitary manner in one of one facility kitchen.

Inspectors wrote2. For R73, the facility staff failed to uphold the resident's dignity by cleaning his fingernails. R73 was admitted to the facility with diagnoses that included but were not limited to hemiparesis (1) and hemiplegia (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/09/2024, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R73 was moderately impaired of cognition for making daily decisions. Under Section GG Functional Abilities and Goals. Subsection I. Personal Hygiene. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) it coded R73 as 01(zero-one)- Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. [...]

Inspectors wroteBased on observation, resident interview, staff interview, facility document, and clinical record review, the facility staff failed to maintain a clean, home-like environment for one of 50 residents in the survey sample, Resident #23.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a written notification upon transfer for one of 50 residents in the survey sample, Resident #27.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure accurate MDS assessments for one of 50 residents in the survey sample; Resident #79.

Inspectors wroteBased on observation, staff interview, clinical record review, it was determined that the facility staff failed to follow the comprehensive care plan for three of 50 residents in the survey sample, Residents #73 (R73), R413 and R80.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, it was determined that the facility staff failed to provide ADL(activities of daily living) care for one of 50 residents in the survey sample, Resident #73 (R73). For R73, the facility staff failed to clean his fingernails. R73 was admitted to the facility with diagnoses that included but were not limited to: hemiparesis (1) and hemiplegia (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/09/2024, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R73 was moderately impaired of cognition for making daily decisions. Under Section GG Functional Abilities and Goals. Subsection I. Personal Hygiene. [...]

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for one of 50 residents in the survey sample, Resident #413. For (R413), the facility staff failed to maintain the oxygen flow rate at three liters per minute according to the physician's orders. R413 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). R413's MDS (minimum data set) assessment was in process at the time of the survey, therefore R413's data was not available. The facility's Admission/readmission Evaluation dated 05/24/2024 for R413 documented in part, A. Cognitive/Neurological. 1. Mental Status: a. Alert. 2. Oriented to: a. Person, b. Place, c. Time, d. Situation. [...]

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for one of 50 residents in the survey sample; Resident #79.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to follow infection control practices during the medication administration for one of six residents in the medication administration observation, Resident #32 (R32). For R32, the facility staff failed to dispose of medications that were spilled out onto the top of the medication cart and were administered. On 06/04/2024 at approximately at approximately 8:04 a.m., an observation of LPN (licensed practical nurse) #7 during the medication pass was conducted. Observations of PLN #7 revealed she removed six medication bubble packs for R32 from the middle drawer of the medication cart and placed them on top of the medication cart. [...]

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to preserve resident dignity when serving meals in one of one facility kitchen. The facility staff served the 7/19/22 lunch meal on disposable Styrofoam containers for all residents, and gave disposable eating utensils to the final seven residents served from the tray line.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to maintain confidentiality of residents' medical records for 4 of 33 residents in the survey sample, Residents #7, #88, #25 and #96.

Inspectors wroteBased on staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when 4 out of 33 residents in the survey sample were transferred to the hospital; Residents #37, #40, #350 and #1.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of written RP (responsible party) and/or ombudsman notification was provided for 4 of 33 residents, Residents #37, #40, #29 and #1.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when 3 out of 33 residents in the survey sample were transferred to the hospital; Residents #37, #40 and #1.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement the comprehensive care plan for 6 of 33 residents in the survey sample, Residents #82, #88, #37, #25, #83 and #94.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide care and services in accordance with professional standards of practice and comprehensive care plan for 4 of 33 residents in the survey sample, Residents #82, #88, #83 and #19.

Inspectors wroteBased on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 33 residents in the survey sample, Resident #37.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain sufficient dietary staff to meet the needs of the residents at the lunch meal on 7/19/22 in one of one facility kitchens. There was insufficient staff from the dietary department working at lunch on 7/19/22, resulting in residents' not receiving lunch at a time compatible with community standards, and resulting in residents being served on disposable dishes.

Inspectors wroteBased observation, staff interview, and facility document review, it was determined that the facility staff failed to serve a meal at a time compatible with community standards in one of one facility kitchens. The facility staff did not begin to serve the lunch meal on 7/19/22 until 1:25 p.m. The final resident tray was not distributed until 2:30 p.m.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens. The cook's refrigerator had two opened, unlabeled items. The stove top and convection oven were dirty. OSM (other staff member) #1, the dietary manager, failed to take the holding temperatures of hot, perishable foods on the tray lines prior to serving them on 7/19/22. Trays for individual resident meals were wet nesting, and a dietary staff member used the same drying towel to dry all of them.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to evidence required annual continuing education (in-service) hours for five of five CNA (certified nursing assistant) records reviewed, CNAs #2, #3, #4, #5, and #6. For CNAs #2, #3, #4, and #5, the facility provided no evidence of dementia training in the past year. For CNA #6, the facility provided no evidence of dementia or abuse training in the past year.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to act upon a reported grievance for a missing personal item for one of 33 residents in the survey sample, Resident #32 (R32).

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to complete a comprehensive assessment with a change in ADL (activity of daily living) status for one of 33 residents in the survey sample, Resident #25 (R25).

Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide an accurate assessment for one of 33 residents, Resident #37. The facility staff failed to complete an accurate MDS (minimum data set); annual assessment for Resident #37.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to actively assist one of 33 residents in the survey sample with discharge planning for a resident requested discharge, Resident #32 (R32).

Inspectors wroteBased on staff interview and clinical record review, it was determined the facility staff failed to assess for a decline in functional status for one of 33 residents in the survey sample, Resident #25 (R25).

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents per resident choice for 2 of 33 residents in the survey sample, Resident #32 (R32) and Resident #22 (R22).

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer oxygen per the physician order for one of 33 residents in the survey sample, Resident #94 (R94).

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide medically related social services to one of 33 residents in the survey sample, Resident #32 (R32).

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to serve food at palatable taste and temperature for 3 of 33 residents in the survey sample, Residents #49 (R49), #28 (R28), #41 (R41). The facility staff failed to serve food at a palatable taste and temperature at lunch on 7/19/22.

Inspectors wroteBased on observation and interview, the facility failed to provide the email address of the State Long-Term Care Ombudsman, in the posted information on the wall by the elevators on the ground, first and second floors.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for two of 41 residents in the survey sample, Residents #80 and #55. The facility staff failed to transcribe a physician order for Resident #80's bilateral knee braces accurately to the TAR (treatment administration record). The facility staff failed to clarify multiple as needed pain medication orders for Resident #55 to determine when and which medication to administer based on pain level parameters.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to serve food in a sanitary manner. During the lunch meal on 3/3/2020, OSM (other staff member) #4, a dietary aide, was observed plating food for resident trays. OSM #4 touched multiple items while wearing gloves and then wearing the same gloves touched the food contact, surface area of plates, and grabbed dinner rolls with his hand, placing one on each plate, wearing the same gloves.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to ensure a complete and accurate medical record for one of 41 residents in the survey sample, Resident # 7. The facility staff failed to document the percentage of food eaten by Resident #7 at meals.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to ensure the kitchen area was free of pests. Two flies were observed flying in the area where dishes were stored on racks for air-drying, and a fly was observed flying around the area of the steam table where the lunch meal foods was already set up but were covered.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to promote resident dignity for two of 41 residents in the survey sample, Residents # 82 and # 43. During the lunch meal service on 3/3/2020 Resident #82 and #43, did not receive their meal for approximately 19 minutes, after staff served the five other residents seated at the same table, and the residents were eating their meals.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to immediately notify and consult the physician for a change in condition, for one of 41 residents in the survey sample, Resident #93. The facility staff identified an unstageable wound on Resident #93's left heel on 11/19/19, and failed to immediately notify and consult the physician and wound care nurse about the wound and treatment initiated, until 11/22/19.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the facility abuse policy for reporting an allegation of abuse for one of 41 residents in the survey sample, Resident #89. Resident #89 alleged a CNA (certified nursing assistant) had abused him causing a scratch on the left elbow that was bleeding on 2/21/2020 at 5:30 a.m. The facility staff did not report the allegation to the State Agency until 2/21/20 at 11:21 AM, approximately five hours and fifty-one minutes after the alleged abuse occurred.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to report an allegation of abuse in a timely manner for one of 41 residents in the survey sample, Resident #89. On 2/21/2020 at 5:30 a.m., Resident #89 alleged a CNA (certified nursing assistant) had abused him causing a scratch on the left elbow that was bleeding, and was not reported to the State Agency until 2/21/20 at 11:21 AM, five hours and fifty-one minutes after the alleged abuse occurred.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence an accurate PASARR (preadmission screening and resident review) screening for one of 41 residents in the survey sample, Resident #69. The facility failed to ensure an accurate PASARR was completed upon admission for Resident #69.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 41 residents in the survey sample, Resident #348. The facility failed to develop a baseline care plan to include and address the care of Resident #348's PICC (peripherally inserted central catheter).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to ensure a complete and accurate medical record for one of 41 residents in the survey sample, Resident # 7. The facility staff failed to document the percentage of food eaten at meals for Resident #7.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to provide treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for two of 41 residents in the survey sample, (Residents # 4 and Resident #7). The facility staff failed to ensure Resident #4 received only nectar-thickened liquids per the physician orders. On 3/3/2020 during the lunch meal CNA (certified nursing assistant) # 3, was observed providing Resident # 4 two sips thin consistency juice by use of a straw. The facility staff failed to administer Mighty House Shake [liquid dietary supplement] to Resident # 7 according to the physician order.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for the prevention and treatment of pressure injuries for two of 41 residents in the survey sample, Residents #80 and #93. For Resident #93 the facility staff failed to provide care and services for the treatment of a pressure wound once identified, for 3 days. On 11/19/19, the facility staff identified an unstageable wound on the left heel. The physician and wound care nurse were not notified of the wound and treatment was not initiated until 11/22/19. [...]

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that facility staff failed to ensure a PPD [purified protein derivative] [1] vial was dated when opened and an expired PPD vial were not available for use in one of one medication storage rooms inspected, second floor medication room.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to implement infection control practices for one of 41 residents in the survey sample, Residents # 4. During the lunch meal observation on 3/3/2020, CNA (certified nursing assistant) #3 was not observed sanitizing or washing their hands while after assisting a resident with their meal and before they resumed assisting Resident #4 with their meal.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to serve food at palatable temperatures for meal enjoyment during the lunch meal service on 3/3/2020.