Belmont Healthcare Center

Inspectors wroteBased on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for food preparation equipment. This practice had the potential to affect all residents. Facility census: 60.

Inspectors wroteBased on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for food preparation equipment. This practice had the potential to affect all residents. Facility census: 60.

Inspectors wroteBased on Resident Council, and staff interviews, the facility failed to provide residents with the right to send and receive mail on Saturdays. This has the potential to affect more than a limited number of residents. Residents identified: #55, #20, #10, #33, #50, #39, #22, #45, #24 and #30. Facility census: 60.

Inspectors wroteBased on a review of a facility reported incident (FRI) and staff interviews, the facility failed to use the investigation results to determine the appropriate action regarding sexual abuse. This was true for two (2) of five (5) residents reviewed for abuse during the Long-Term Survey Process. Resident identifiers: #56 and #67. Facility census: 60.a) Resident #67 A review of the facility reportables found a sexual abuse allegation, dated 03/17/26, which involved Resident #67 reporting, Someone tried to rape me last night. She reported she was lying in bed asleep when she felt Resident #32 pulling on her leg. Resident #67 reported she wasn't sure what the man was doing, but she thought he was going to try to rape her. Employee #78 reported she was charting when she heard Resident #67 yelling. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the resident environment was as free from accident hazards as possible. This was a random opportunity to discover a blender storage area and medication carts unlocked and unattended. Facility Census: 60.

Inspectors wroteBased on food tray temperatures, resident interviews and staff interviews, the facility failed to serve food that was attractive, palatable and at a safe and appetizing temperature to prevent foodborne illness. Residents identified: #47, #33, #42 and #9. Facility census: 60 On 4/28/26 12:00 PM it was noted that the kitchen staff were not taking and recording temperatures for items on the always available menu. Before the surveyor brought it to the Director of Dining Services' (DDS) attention, the beef patties, hotdogs and brown gravy lacked recorded temperatures prior to the start of the lunch meal service. The DDS acknowledged they had not been taking and recording these food items' temperatures and will educate the staff to start doing so as soon as possible. The DDS stated, The always available menu item temperatures are not being recorded. [...]

Inspectors wroteBased on observations, clinical record reviews, facility documentation, and staff interviews, it was determined that the facility failed to establish and maintain an infection prevention program to prevent the development and transmission of communicable diseases related to hand hygiene. This practice had the potential to affect more than an isolated number of residents. Facility census: 60.

Inspectors wroteThe facility failed to maintain the confidentiality of resident records, as evidenced by leaving a medicine cart's computer screen unlocked with resident information on display. This failed practice has the potential to affect more than a limited number of residents. Facility census: 60.

Inspectors wroteBased on observation and resident interviews, the facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with their assessed needs for care. This was true for one (1) of three (3) residents reviewed for ADL care. Resident Identifier: #26. Facility census: 60. Findings Included:a) Resident # 26During an interview and observation conducted on 04/27/26 at 11:28 AM, the surveyor met with Resident #26, who had visible facial hair. The resident stated that her preference was to receive assistance with shaving; however, she noted that she does not always receive this help. During an Interview on 04/27/26 at 1:08 PM the Director of Nursing (DON) verified that Resident #26 had visible facial hair and that he would have staff assist her with getting shaved.

Inspectors wroteBased on record review and staff interview the facility failed to ensure professional standards of practice were followed in regards to completing neurological assessments following a fall. This was true for one (1) of 25 residents reviewed during the long term are survey process. Resident Identifier: Resident #13. Facility Census: 60.

Inspectors wroteBased on observation and staff interviews, the facility failed to store, prepare, and serve food in a safe and sanitary manner by not removing dented cans from service. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 60.

Inspectors wroteBased on observation and interview, the facility failed to maintain effective infection control practices in the laundry room. Additionally, facility staff failed to adhere to infection control policies and protocols while providing catheter care. Resident Identifier: #44. Facility Census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a correct capacity form for Resident #23 and failed to correctly document dates and times of neurochecks for Resident #13. Resident identifiers: #23 and #13. Census:

Inspectors wroteBased on observation and interview, the facility failed to ensure that residents had a means of contacting their caregivers through a call system that was accessible to them while in their bed, or other sleeping accommodations within their room. Resident Identifiers: #46 and #38. Facility Census: 60.

Inspectors wroteBased on record review, observation, resident and staff interview, the facility failed to ensure that residents were free from physical abuse. Multiple incidents took place in which Resident #2 was physically abusive to other residents in the facility. The facility failed to take necessary action to prevent further abuse. This created an immediate jeopardy sitaution for more than an isolated number of residents. Resident identifiers: #1,# 2, #3,# 4, #57. Facility census: 65.

Inspectors wroteBased on record review and resident and staff interview, the facility failed to ensure the psychosocial wellbeing of a resident was met following a traumatic event, due to failing to follow up with Resident #1 to assess her psychosocial wellbeing and make necessary referrals for Resident #1 to maintain her psychosocial wellbeing. Multiple incidents took place in which Resident #2 was physically abusive to other residents in the facility. The facility failed to take necessary action to prevent further abuse. This created an immediate jeopardy situation. Resident identifiers: #1,and #2. Facility census:

Inspectors wroteBased on resident facility record review, medical record review, and staff interview, the facility failed to ensure that a resident's respiratory care was provided consistent with professional standards of practice. A resident's oxygen concentrator was set at a lower liter than ordered. This was a random opportunity for discover identified during a complaint survey. Resident identifier: #66. Facility census: 65.

Inspectors wroteBased on record review and staff interview the facility failed to implement written policies and procedures that ensured investigations into allegations of abuse and neglect were thoroughly investigated. This failed practice was true for 1 (one) of 6 (six) investigations reviewed. Resident identifiers: #64. Facility census: 64.

Inspectors wroteBased on record review, staff interview and the facility policy and procedure, the facility failed to provide evidence that all alleged violations were thoroughly investigated and that corrective action was taken. Witness statements and staff education was not thoroughly completed. This was true for one (1) of five (5) facility reported incidents reviewed during the complaint survey. Resident identifier: #64. Census: 65. a) Resident #64 On 05/20/24 at 11:30 AM a review of the FRI complaint and investigation was performed. It was noted that on 04/01/24 at approximately 12:00 PM, Resident #64 was in the facility dining room, she requested to be taken back to her room stating she needed to have a bowel movement. Employee #56 reported she took Resident #64 down the hall to Employee #70. [...]

Inspectors wroteBased on record review and staff interview the facility failed to implement written Quality Assurance and Performance Improvement (QAPI) polices and procedures for data collection and monitoring including adverse event monitoring. This failed practice was true for 6 (six) of 6 (six) investigations reviewed. Resident identifiers: Resident #64, #66. Facility census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to revise care plans for one (1) of six (6) residents. Resident #64's care plan was not revised to reflect the resident's ability to use the FreeStyle Libre blood glucose monitoring system. Resident #2's care plan was not revised to reflect her aggression toward other residents. Resident identifiers: #64, #2. Facility census: 65.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed. This was identified during the extended survey process of the complaint survey. This has the potential to affect a limited number of residents. Identifier: Recreational Director (RD) #60. Census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain accurate medical records as it pertained to behavior monitoring for Resident #1. Resident identifier: 2. Facility census: 65.

Inspectors wroteBased on medical record review, observation and staff interviews the facility failed to ensure the patient care equipment was in safe operating condition. A concentrator was identified to have overheated and not working for a resident. This was true of one (1) of three (3) residents with oxygen concentrators in use and was identified during the complaint survey. This had the ability to affect a limited number of residents. Resident identifier: #34. Facility census: 65.

Inspectors wroteBased on medical record review and staff interview, the facility staff failed to accurately complete comprehensive assessments reflecting Hospice services and anticoagulants. This is true for two (2) of two (2) residents reviewed for Hospice and two (2) of two (2) residents reviewed for inaccurate assessments. Resident identifiers: #38, #44 and #46. Facility census: 61.

Inspectors wroteBased on deficiencies cited, resident interviews, record reviews, and review of the facility assessment, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental, and psychosocial well-being. Facility census: 61. Findings Included: a) Citations During the facility's long-term care survey the following citations are cross referenced for F725: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored and administered in accordance with current accepted professional practices to ensure the safety and efficacy of medications administered. Medications stored in one (1) of two (2) medication carts inspected, had medication that was being administered after the manufacturer use by date. Temperatures were not obtained for the medication room refrigerator to ensure proper storage of medications requiring refrigeration. This practice had the potential to affect more than a limited number of residents. Resident Identifier: Resident #1. Facility census: 61.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to serve food that was palatable and at an accurate temperature. This failed practice had the potential to affect more than an isolated number of residents. Facility census 61. Findings Included: A review of the facility policy entitled HCSG 016 Food: Preparation with an effective date of 05/2014 and revision date of 09/2017 stated: .13. All foods will be held at appropriate temperatures, greater than 135 degrees F (Fahrenheit) (or as state regulation requires) for hot holding, and less than 41 degrees F for cold food holding . a) Tray Line On 10/18/22 at 11:25 AM, Food Services Director #56 obtained temperatures from the tray line prior to the meal service. The following foods did meet the temperature guidelines: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were opened. The facility also failed to accrue dishwasher, refrigerator, freezer and resident refrigerator temperature logs. This failed practice had the potential to affect more than a limited number of residents who are served food from the kitchen. Facility census: 61.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record for one three (3) of 20 sample residents reviewed during the Long-Term Care Survey process. Resident identifiers: #48, #111, and #20. Facility census: 61.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure care was provided in a manner to promote the resident's dignity. A sign was posted in Resident #46's room noting direction for care or treatment. This failed practice was based on a random opportunity for discovery and had the potential to effect more than a limited number of residents. Resident identifier: Resident #46. Facility census:

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for two (2) of two (2) residents reviewed for Hospice. Resident identifiers: #38 and #44. Facility census: 61.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents unable to carry out activities of daily living (ADLs) received necessary services in the areas of dressing and personal hygiene. This was true for nine (9) of 20 residents reviewed under the care area of activities of daily living during the long-term care survey process. Resident identifiers: #1, #47, #31, #112, #28, #27, #22 and #8. Facility census: 61. a) Resident #1 On 10/18/22 at 8:55 AM, an interview with Resident #1 was completed. Resident #1 stated I'm supposed to get my showers Monday, Wednesday and Fridays .There was a new girl and she didn't know anything about it. She said we don't give showers on evening shift anymore. On 10/18/22 at 3:24 PM, an interview with the Administrator regarding the shower schedule was held. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide the necessary treatment and services to promote healing of pressure ulcer. This failed practice was true for one (1) of four (4) residents reviewed for pressure ulcer care. Resident identifier: #55. Facility census: 61.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and prevent complications of enteral feeding. The facilty failed to ensure the residual amounts were obtained in accordance with the physician's orders. This was true for one (1) of two (2) residents reviewed who was receiving a tube feeding during the Long Term Care Survey Process. (LTCSP). Resident identifier: #111. Facility census: 61.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide oxygen therapy in accordance with professional standards and practices. The facility failed to ensure the flow rate of oxygen was administered in accordance with physician's orders. This failed practice was true for one (1) of two (2) residents receiving oxygen therapy, reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: Resident #111. Facility census: 61.

Inspectors wroteBased on observation and interview, the facility failed to keep waste properly contained when the dumpster was overfilled and uncovered. This failure had the potential to result in unpleasant odors and harboring of pests. Facility census: 61.