Belterra Health & Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care to four of eight residents (Residents #56, #83, #109, and #120) reviewed for baseline care plan. 1. The facility failed to ensure Residents #56 had a baseline care plan after admission to the facility on [DATE]. 2. The facility failed to ensure Residents #83 had a baseline care plan after admission to the facility on [DATE]. 3. The facility failed to ensure Residents #109 had a baseline care plan after admission to the facility on [DATE]. 4. The facility failed to ensure Residents #120 had a baseline care plan after admission to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received adequate supervision to prevent accidents and/or hazards for 3 (Residents #68, #107, and #110) of 8 residents reviewed for supervision and accidents/hazards.1. The facility failed to ensure there were no germicidal wipes on Resident #107's side table on 04/21/2026.2. The facility failed to ensure there were no germicidal wipes on the floor, in front of Resident #110's room on 04/21/2026.3. The facility failed to ensure Resident #68 received adequate supervision allowing Resident #68 to exit the facility without the knowledge of staff on 04/13/2026 for approximately 20 minutes. Resident #68 was located at Walgreens, which is parallel to the facility approximately 528 yards from the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for five of twenty residents (Residents #63, #71, #79, #102, and #107) and one of four direct care staff (MA K) reviewed for medication storage. 1. The facility failed to ensure that Resident #71 did not have a pain reliever cream inside his room on 04/21/2026. 2. The facility failed to ensure that Resident #102 did not have a tube of zinc oxide and a bottle of multivitamins inside her room on 04/21/2026. 3. The facility failed to ensure that Resident #63 did not have a tube of zinc oxide inside her room on 04/21/2026. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of twenty residents (Resident #4, #32 and #71) reviewed for infection control. 1. The facility failed to ensure CNA J did not put Resident #4's catheter bag on top of the resident's bed and changed her gloves after touching the catheter bag on 04/22/2026. 2. The facility failed to ensure CNA H performed hand hygiene and changed her gloves during Resident #32's incontinent care on 04/22/2026. 3. The facility failed to ensure CNA G wore a gown when she emptied Resident #71's catheter bag and when she checked if the resident was wet on 04/21/2026. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during personal care and confidentiality of personal and medical records for one of twenty residents (Resident #4) reviewed for privacy and confidentiality. The facility failed to ensure CNA I and CNA J closed the blinds of Resident #4's window, which was overlooking the parking lot, during incontinent care on 04/22/2026. This failure could place the residents at risk of not having their personal privacy maintained while care was provided, which could result in the residents feeling uncomfortable during care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one of twelve residents (Resident #26) reviewed for care plans. The facility failed to ensure that Resident #26 had a care plan for her BiPAP on 04/21/2026. This failure could place the residents at risk of not receiving the necessary care and services.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of five residents (Resident #4) reviewed for incontinent care. The facility failed to ensure that CNA J did not place Resident #4's catheter on top of the Resident #4's bed rendering the catheter not below the bladder for the duration of incontinent care on 04/22/2026. This failure could place the residents at risk of backflow of urine resulting to urinary tract infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #26) reviewed for respiratory care. The facility failed to ensure Resident #26's BiPAP mask was properly stored when not in use on 04/21/2026. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of ten residents (Resident #83) reviewed for pharmaceutical services. The facility failed to ensure LVN F did not administer Resident #83's esomeprazole along with the other medications and the resident's formula on 04/22/2026. This failure placed residents at risk of not receiving the full benefit of their medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the nurse staffing data information was posted daily for 1 of 1 facility reviewed for required postings. The facility failed to post the daily staffing information for 04/20/26. This failure could place residents, family members, and visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (east side medication room) of two medication rooms reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the east side medication room. These failures could place residents at risk for infection and having possible adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #29) of 19 residents reviewed for medication errors. The facility failed to ensure Clonazepam (a drug used to control seizures and/or anxiety) was administered to Resident #29 as ordered from 9/10/2024 until 2/12/2025 (155 days). This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and secured properly for two (500 hall medication cart and 200 hall medication cart) of four medication carts reviewed for medication labeling and storage. 1. The facility failed to ensure eye drops stored on the 500-hall medication cart were labeled with open dates for two bottles of timolol eye drops, one bottle of dorzolamide eye drops, one bottle of brimonidine eye drops, and one bottle of latanoprost eye drops. 2. The facility failed to ensure medications were secured or attended by authorized staff when the medication cart in hall 200 was left unlocked and unattended in the hallway with a pill in a medicine cup on top of the cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's main kitchen reviewed for food safety. 1. The facility failed to ensure food items in the refrigerator and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerator or dry storage that were not properly labeled or past the 'best buy', discard by or expiration dates. 3. The facility failed to have dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. 4. The facility failed to have the handwashing sink trash receptacles function properly. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to establish and maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for one (Resident #85) of three residents reviewed for infection control. The facility failed to ensure RN D used proper infection control precautions when entering the room of Resident #85 who was on droplet precautions due to testing positive for COVID. This failure could place residents at risk for infections.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's kitchen, reviewed for kitchen sanitation. The facility failed to ensure food in the facility's walk-in refrigerator was covered. The facility failed to ensure the ice machine was clean and sanitized. The facility failed to ensure the tea was covered with a lid. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #310, Resident #102, Resident #21, Resident #83, and Resident #68) of eight residents reviewed for infection control. 1. RN C failed to prevent cross contamination of Resident #310's Insulin pen when he placed a soiled glucometer next to the pen and then administered insulin to the resident with the soiled pen. 2. CNA B failed to perform hand hygiene during incontinence care for Resident #102. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two of ten residents (Resident #59 and Resident #77) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #59 and #77's rooms were in a position that was accessible to the residents. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #102) of two residents reviewed for incontinence care. The facility failed to ensure CNA B provided appropriate perineal care for Resident #102 after an incontinent episode when she failed to wipe from the base of the labia towards and extending over the resident's buttocks. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.

Inspectors wroteImmediate Supervisor: [NAME] Alfafara Based on observation, interview, and record review, the facility failed to ensure that a resident, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #72) reviewed for respiratory care. The facility failed to ensure Resident #72's nebulizer tubing was changed weekly as scheduled. This failure could place the resident at risk for respiratory infection and not having their respiratory needs met.