Belmont Healthcare Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food were stored and prepared in a sanitary manner when these were observed during kitchen tour:There was a dirty window screen next to an interior air conditioning (A/C) unit. There was a water collection tray under an interior A/C unit. There was a dirty filter screen on an interior A/C unit. Floors were not cleaned when: A. Two packets of creamers and four packets of sugar were found on the floor under a storage shelve; B. a small container of sherbet (frozen desert) and a used paper towel were found on the floor under a freezer. These failures had the likelihood for food items to be stored and prepared in an unsanitary environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident representative (RR) for one of three sampled residents (Resident 1) were notified of a significant change in condition when Resident 1 experienced an unwitnessed fall with head injury. The RR was not notified until approximately more than seven hours after the incident, despite Resident 1 having impaired cognition and sustaining a documented head injury. This failure resulted in delayed awareness of Resident 1's condition by the RR, which hindered RR's timely involvement in care decisions. During a review of Brief Interview for Mental Status (BIMS) dated 01/26/2026 at 9:04 AM, the Brief Interview for Mental Status (BIMS) indicates Resident 1 has a BIMS score of 3, which means Resident 1 has severely impaired cognitive function. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the accuracy of the Minimum Data Set (MDS, an assessment tool) for two (2) of six (6) sampled residents (Residents 1 and 2) when: 1. For Resident 1, the number of Pressure Injury (PI, a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure, or pressure in combination with shear), Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence), was inaccurately coded as two (2) instead of one (1) on the MDS, section M. 2. For Resident 2, the number of PI, Stage 3 (full thickness tissue loss. Subcutaneous fat maybe visible but bone, tender or muscle is not exposed. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) and wore the appropriate personal protective equipment (PPE) while providing care for 1 (Resident #25) of 2 residents reviewed for tube feedings.

Inspectors wroteBased on interview and record review, the facility failed to implement fall care plans for two of 3 sampled residents (Resident 1 and Resident 2) when there was no evidence of frequent monitoring. This failure had the potential to delay the identification of needs, functional and health status for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse. A Physical Therapist (PT) reported she saw a nurse (RN 1) slapped Resident 4's hand and was yelling at him to wake him up. Failure to thoroughly investigate an allegation of abuse did not ensure residents were protected from abuse.

Inspectors wroteBased on interview, and record review, the facility failed to update the fall care plan for one of 3 sampled residents (Resident 3) when there was no evidence that the fall care plan was updated after her fall on [DATE]. This failure had the potential to put the resident at risk of not receiving appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Dietitian (RD) working full-time or part-time at the facility from January to April 2024. Failure to have a RD working at the facility did not ensure residents were assessed appropriately to maintain the residents' weight and other nutritional parameters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications and biologicals (biologicals are made from variety of natural sources- human, animal or microorganisms, may include a wide range of products such as vaccine, blood and blood components) in a safe condition when the temperature of two of two sampled medication refrigerators were out of range in accordance with Federal, State, and CDC vaccine storage and handling guidelines. This failure had the potential to compromise the integrity and effectiveness of medications and biologicals and could potentially cause harm to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure competency of one dietary aide (DA) when: 1. Standardized recipes for pureed foods were not followed for three lunch menu items on 11/16/21. 2. Scoop sizes for pureed foods were not followed during lunch tray line service on 11/16/21. Failure to ensure staff competency in kitchen related duties could negatively impact provision of prescribed diets and preferences for 13 residents who received pureed food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Food items stored in kitchen refrigerators were expired, not labeled and dated, had labels beyond dates of use, produce discolored and fruits had mold-like substance 2. Food item brought in by family member for a resident was stored in the kitchen refrigerator 3. Food items stored in dry storage room were not dated and stored properly 4. Equipment and food service trays were not cleaned and maintained properly, and dietary staff did not perform proper hand hygiene 5. Temperature in freezer was out of range This deficient practice had the potential to put residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights for six residents were maintained to ensure call lights were functioning as intended. Five call lights did not light up inside the resident's room when activated (Residents 21, 27, 38, 46, and 60). Resident 35's call light was not functioning when checked. Failure to maintain indicator lights had the potential to increase a resident's anxiety when there was no visual indication to let a resident know if their call light was functioning. Failure to ensure Resident 35's call light was functioning had the potential to delay staff's response to Resident 35's request for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1. Dresser surfaces covered with Formica (a thin plastic laminate glued onto furniture to provide a durable surface) in rooms [ROOM NUMBERS] were free of chipped damage. 2. The chipped and cracked surface of an enameled sink (metal sink coated with a shiny hard ceramic layer) in room [ROOM NUMBER] was repaired and/or replaced. These failures had the potential for surfaces not to be cleaned in a sanitary manner and may negatively impact residents' psychosocial health when they have to live in an unmaintained room that is not homelike.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are protected from abuse when a verbal abuse allegation incident that involved Resident 42 and Resident 44 was not identified and reported to appropriate agencies within two hours after knowledge of the allegation. This failure put residents at risk from from further abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to appropriate agencies within the required timelines when a verbal abuse allegation incident that involved Resident 42 and Resident 44 was not identified. This failure may result in further potential abuse of residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the colostomy (surgical opening in the intestine) care plan and the self-care/Activities (ADL, Activities of Daily Living) care plan for one of 17 sampled residents [Resident 11] were implemented and updated in accordance with Resident 11's current assessed needs. Failure to implement care plan interventions to teach Resident 11 how to manage her colostomy had the potential for Resident 11 to be continually dependent on staff for colostomy care. Failure to update Resident 11's care plan indicated staff was not following the facility's policies and procedures regarding updating care plans on a quarterly basis. This had the potential for outdated and/or inaccurate information to remain in Resident 11's care plans. Definitions: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement restorative nursing program (RNP, exercises or activities designed to maintain or improve residents' abilities to the highest practicable level such as: range of motion exercises, splint or brace assistance, training and skills practice in bed mobility, transfers, walking, dressing, grooming, eating, communication, etc.) for 3 out of 29 sampled residents (Resident 9, Resident 59, and Resident 45 on RNP when: 1. RNP physician's orders for Resident 9, Resident 59, and Resident 45 were unclear. 2. RNP was not provided to Resident 9, Resident 59, and Resident 45 as ordered by the physician. These failures had the potential for residents to decline or not maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 44's behavior was appropriately monitored and evaluated by staff since admission into the facility. This failure had the potential for Resident 44 to not attain or maintain her highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility had a 27.5 % medication error rate when eight medication errors out of 29 opportunities were observed during medication pass for Residents 29, 55, 56, and 325. These medication errors resulted in Resident 29 not receiving his blood pressure medication in a timely manner. Additionally, staff failed to follow the manufacturers' recommendations and/or the facility policies and procedures for eye drop and inhaler administrations. These failures may result in sub-therapeutic administration of eye drops to Resident 29, 55, 56, and 325, and sub-therapeutic administration of inhalers to Residents 29 and 325.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and sanitary storage, handling and consumption of food items brought to residents by family members and other visitors. This failure had the potential to expose residents to food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed their infection control practices, when two staff members did not perform hand hygiene before entering Residents' rooms. This deficient practice had the potential for staff to spread infectious agents to residents within the facility.