Belmont Health & Rehabilitation

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications kept at bedside for 1 of 1 resident reviewed for self-administration (Resident #39).

Inspectors wroteBased on observation, record review, interviews with staff and Nurse Practitioner, the facility failed to follow a Nurse Practitioner order for the care of an intravenous (IV) access site for 1 of 1 resident who had a Peripherally Inserted Central Catheter (PICC) (Resident #85).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) prior to discharge from Medicare Part A skilled services for 3 of 3 residents reviewed for beneficiary notification review (Residents #57, #90 and #92). The Findings Included: 1. Resident #57 was admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with Resident #57's Responsible Party (RP) on 08/20/24 which indicated Resident #57's Medicare Part A coverage for skilled services would end on 08/23/24. Resident #57 remained in the facility. Review of Resident #57's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #57 or Resident #57's RP. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain residents' wardrobe closets in good repair by not replacing knobs on the drawers which left exposed screws sticking out from the drawer that had the potential to cut residents when entering and exiting their rooms (rooms 202, 208, 215, 223, and 225); failed to ensure a resident's wardrobe closet had functioning drawers (room [ROOM NUMBER]); failed to maintain a clean and sanitary wheelchair (room [ROOM NUMBER]-A); and failed to ensure a call light cover was secured to the wall in a resident's bathroom to prevent it from coming loose when the cord was pulled to engage the call light (room [ROOM NUMBER]) for 8 of 31 rooms on 1 of 2 resident halls (200 hall) reviewed for environment.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure Registered Nurse (RN) coverage was provided for at least 8 consecutive hours per day for 4 of the 91 days reviewed for RN Coverage (5/04/24, 5/18/24, 5/25/24, and 6/08/24).

Inspectors wroteBased on observations and staff interviews the facility failed to maintain a clean floor in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer, and 1 of 1 kitchen; label and date open food items and discard food with signs of spoilage or use-by date in 1 of 1 walk-in cooler; restrain facial hair during food preparation; and label and date food items in 2 of 2 nourishment room refrigerators and freezer (first and second floor nourishment rooms).

Inspectors wroteBased on observations and staff interviews the facility failed to ensure the area surrounding dumpsters remained free of garbage and debris and failed to close the doors to the dumpsters that contained waste for 3 of 3 dumpsters reviewed. These failures had the potential to attract pests and rodents.

Inspectors wroteBased on record review, staff and Consultant Pharmacist interviews, the facility failed to follow the pharmacy recommendation to update a medication order to include indication for use for 1 of 5 residents reviewed for unnecessary medications (Residents #77).

Inspectors wroteBased on record review and staff interviews, the facility failed to post complete and accurate daily licensed nurse staffing information for 19 of the 20 days reviewed 5/04/24, 5/18/24, 5/25/24, 6/08/24, and 1/01/25 through 1/16/25 for sufficient staffing and failed to maintain a posted staffing sheets for one day (5/25/24).

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated dietary concerns voiced by residents during Resident Council meetings for 4 of 9 months reviewed (January 2023, April 2023, May 2023, and July 2023).

Inspectors wrote5. An in-room observation conducted on 10/03/23 at 10:00 AM of room [ROOM NUMBER] revealed an outlet cover was missing leaving the cutout in the wall exposed through the adjoining room (room [ROOM NUMBER]) with male resident. On 10/5/23 at 9:56 AM an observation of room [ROOM NUMBER] revealed the cutout in the wall to be unchanged. Resident #73 was interviewed during the observation. She stated the cutout in the wall had been there since she moved into the room. On 10/05/23 at 4:15 PM the Maintenance Manager and the Administrator reported they were not aware of the missing outlet cover for room [ROOM NUMBER], and it would be repaired. 2. a. Observations of room [ROOM NUMBER] on 10/02/23 at 3:31 PM, 10/03/23 at 9:22 AM, 10/04/23 at 9:13 AM, 10/05/23 at 8:52 AM, and 10/06/23 at 12:04 PM revealed a wardrobe closet located just inside the room door. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to ensure performance reviews were completed every 12 months for 4 of 4 Nurse Aides (NAs) reviewed to ensure in-service education was designed to address the outcome of the performance reviews (NA #1, NA #2, NA #3, and NA #4).

Inspectors wroteBased on record review, observations and staff interviews the facility failed to repair the walk-in refrigerator door seal and remove expired milk stored for use in the walk-in refrigerator. Additionally, the facility failed to maintain a clean and maintain a heating, ventilation, and air conditioning unit (HVAC) located in the kitchen, a vertical pole adjacent to food production, a conduit pipe located above the tray line, and the ceiling area of the dish room free of peeling paint. The practice had the potential to affect the food served to the residents. Findings Included: a. On 10/2/23 at 10:42 AM an observation with the Dietary Manager (DM) of the walk-in refrigerator door seal was observed to be peeling away from the bottom right side door jam and sticking out from the closed refrigerator door. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions previously put in place following the recertification and complaint investigation survey that occurred 10/06/23 and the recertification and complaint investigation survey that occurred 05/20/22. This failure was for 3 deficiencies that were originally cited in the areas of Food Procurement, Store/Prepare/Serve-Sanitary (F-812), Accuracy of Assessments (F-641), and Safe/Clean/Comfortable/Homelike Environment (F-584) and were subsequently recited on the current recertification and complaint investigation survey of 10/06/23. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective QAA program.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure Nurse Aides (NA) received at least 12 hours of in-service training yearly and maintain documentation of the in-service training hours provided for 4 of 4 NA employee records reviewed for staffing (NA #1, NA #2, NA #3, and NA #4).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR), activities of daily living, diagnoses, and skin conditions for 7 of 27 sampled residents reviewed (Residents #8, #55, #72, #3, #15, #18 and #237).

Inspectors wroteBased on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) Level II evaluation for a resident with a history of mental health diagnoses for 1 of 5 sampled residents reviewed for PASRR (Resident #53).

Inspectors wroteBased on record review and staff interviews the facility failed to provide supporting documentation for a resident with a new diagnosis of schizophrenia for 1 of 5 residents reviewed for unnecessary medications (Resident #18).

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to have a discharge planning process in place that incorporated the resident in the development of a discharge care plan that addressed the resident's discharge goals and post-discharge needs for a resident who wished to discharge to the community for 1 of 2 sampled residents (Resident #236).

Inspectors wroteBased on record review and staff, Consultant Pharmacist, and Medical Director interviews the Consultant Pharmacist failed to provide recommendations for laboratory tests for drug monitoring for 1 of 5 residents reviewed for unnecessary medications (Resident #3).