Belmont Manor

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure food that was expired and noted with mold. This affected all 52 residents in the facility. The facility census was 52.

Inspectors wroteBased on record review, and interview, the facility failed to ensure residents or resident representatives knew in advance what charges a facility may impose against a resident's personal funds. This affected four residents (#8, #5, #22, #35 ) of five residents reviewed for personal funds. The facility census was 52.

Inspectors wroteBased on medical record review, hospital record review, staff interviews, review of literature from the American Heart Association, and policy review, the facility failed to timely assess and monitor the cardiopulmonary status, including weights. This affected one resident (#25) of two residents reviewed for hospitalizations. The facility census was 52.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) to reduce the transmission of multidrug-resistant organisms in high contact resident care activities. This affected one resident (#20) of three residents reviewed for pressure ulcers. The facility census was 52.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to ensure sanitary kitchen practices. This had the potential to affect all the individuals in the facility except for Resident #9 who did not receive nutrition from the kitchen. The facility census was 51.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure resident dignity was maintained during use of indwelling urinary catheters for three residents (#6, #12, and #22) and when dining for five residents (#3, #19, #21, #44 and #46). This affected eight residents (#3, #6, #12, #19, #21, #22, #44, and #46). The census was 51.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure comprehensive care plans were revised. This affected four residents (#15, #21, #44 and #46) of 18 residents sampled. The census was 51.

Inspectors wroteBased on observation, test tray, and interview, the facility failed to ensure food was pureed to the correct consistency. This affected four residents (#14, #17, #22 and #23) who receive a pureed diet. The facility census was 51.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure accommodations of resident needs was met when call lights were not readily accessible to residents. This affected one resident (#26) of two residents reviewed for communication-sensory. The facility identified two residents being blind (#3, #26). In addition, based on observation, medical record review, policy review and interview, the facility failed to provide residents with appropriate table heights on the secured unit during meals. This affected one resident(#21) of 14 residents on the secured unit. The census was 51.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure resident information remained private. This affected one resident (#6) during a random observation. The census was 51.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure residents were free from restraints. This affected two residents (#21 and #46) of three residents reviewed for restraints. The facility did not identify any residents having restraints. The census was 51.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure the comprehensive assessments were accurate related to alarms, falls and psychotropic medications. This affected one resident (#46) of 18 residents reviewed for comprehensive assessments. The census was 51.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure residents were provided a written summary of the baseline care plan. This affected one resident (#106) of 18 residents reviewed for care planning.

Inspectors wroteBased on medical record review and interview, the facility failed to develop and implement care plans to maintain a resident's highest practicable well-being. This affected one resident (#46) of 18 residents reviewed for care plans. The census was 51.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure proper positioning of residents during meals on the secured unit. This affected three residents ( #21, #25 and #46) of 14 residents on the secured unit. The census was 51.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure dependent residents received nail and oral care. This affected two residents (#22 and #49) of two residents reviewed for activities of daily living.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to implement physician orders for tubigrips (tubular bandages that provide light to moderate compression) to address edema. This affected one resident (#27) of 24 residents screened for edema (swelling).

Inspectors wroteBased on observation, medical record review, missing item log review, policy review and interview, the facility failed to ensure visual appliances i.e. eyeglasses were readily available for resident use. This affected one resident (#21) of two resident reviewed for communication-sensory. The census was 51.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure pressure relieving measures were in place as ordered. This affected one resident (#34) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, record review, policy and interview, the facility failed to ensure restorative services were initiated, assessed, reviewed and revised if needed. This affected three residents (#12, #21, and #46) of four residents reviewed for positioning, mobility and limited range of motion.

Inspectors wroteBased on observation, medical record review, fall investigation review, policy review and interview, the facility failed to implement interventions and complete accurate investigations to prevent further falls. This affected one resident (#46) of three residents reviewed for accidents. The census was 51.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure treatment and care was provided as ordered for a resident with a history of urinary tract infections and urinary catheter. This affected one resident (#6) of one resident reviewed for urinary catheter.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to ensure a resident with a significant weight loss received medications, supplements and routine meals. This affected one resident (#46) of two residents reviewed for nutrition. The census was 51.

Inspectors wroteBased on medical record review, medication guide review,policy review, and staff interview, the facility failed to provide monitoring for side effects with the use of a psychoactive medication. This affected one resident (#46) of three residents reviewed for unnecessary medications. Findings Include: Medical record review revealed Resident #46 was admitted on [DATE] from the community with diagnoses including dementia, anxiety, major depressive disorder and diabetes mellitus type 2. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #46 was severely impaired for daily decision-making with diagnoses including diabetes mellitus. Review of the electronic Physician Orders dated 07/10/24 revealed to start Rexulti (antipsychotic) 0.5 milligrams one tablet daily. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure an as needed antianxiety medication had a 14 day stop date, and an antipsychotic medication had behaviors documented and an indication for use. This affected two residents (#22 and #46) of five residents reviewed for unnecessary medication. The facility census was 51.

Inspectors wroteBased on record review and interview, the facility failed to ensure an accurate medical record. This affected two residents (#22 and #46) of 19 residents reviewed. The facility census was 51.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure antibiotic orders were reviewed with the resident's attending physician when there was inadequate information to support the presence of an infection and an antibiotic was not in daily use without consultation with a specialist. This affected two residents (#9 and #15) of 24 residents screened for infections.

Inspectors wroteBased on review of infection control logs, observation, policy and interview, the facility failed to ensure catheter care met professional standards and patterns of infection were identified. This affected one resident (#6) of three residents reviewed for indwelling catheters.

Inspectors wroteBased on resident interview, medical record review, fall investigation review and staff interview the facility failed to implement fall interventions as ordered. This affected one (Resident #37) of three residents reviewed for accidents. The census was 40.

Inspectors wroteBased on record review and interview, the facility failed to ensure weights were obtained as ordered for Resident #16. This affected one (Resident #16) of two residents reviewed for weights. The facility census was 40.