Belvedere Center, Genesis Healthcare, the

Inspectors wroteBased on observation, clinical records review, and staff and residents' interviews, it was determined that the facility failed to ensure the resident's dignity was maintained for one of 26 residents reviewed (Resident 93). Findings Include: Review of Resident 93's diagnosis list includes: Spastic Hemiplegic Cerebral Palsy (A neurological condition affecting movement and muscle tone on one side of the body, including the arm, leg, and sometimes the face), Post Traumatic Stress Disorder (PTSD), and Anxiety Disorder (A mental health disorder characterized by feeling of worry, anxiety or fear that are strong enough to interfere with one's daily activities). A review of Resident 93's Annual Minimum Data Set (MDS- a standardized assessment tool that measures health status in long-term care residents) dated July 10, 2026, revealed the resident was cognitively intact. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based upon observation, it was determined the facility failed to ensure medications were properly labeled with open and expiration dates for three of four medication carts observed (North Back Hall Cart, North Front Cart and South Middle Cart).

Inspectors wroteBased on facility policy, clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for 1 of 26 residents reviewed (Resident 134).

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on clinical record review and interview with staff, it was determined that the facility failed to complete a comprehensive assessment within 14 days after a significant change in the resident's condition for one of 26 residents reviewed (Resident 90).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for two of 26 residents reviewed (Residents 95 and 113). Based on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for two of 26 residents reviewed (Residents 95 and 113).

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on policy review, and clinical records review, it was determined that the facility failed to follow physician orders regarding administration of medications for one of 26 resident (Resident 3)

Inspectors wroteNumber of residents sampled: Number of residents cited: Based upon observation, it was determined that the facility failed to ensure medication carts were locked when a staff member was not in attendance for one of four medication carts observed (North Hall Front Cart).

Inspectors wroteBased on a review of the facility's policy, facility documentation, clinical records, and staff interview, it was determined that the facility failed to monitor resident's skin condition and follow wound physician's treatment orders/recommendations resulting in harm to Resident CL1 of discovering the wound at an advanced Stage 3 (full thickness loss of skin that extends into the subcutaneous tissue but does not cross the fascia beneath), wound deterioration, and unnecessary pain/discomfort for one of two residents reviewed (Resident CL1).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to maintain resident dignity for one of one residents (Resident 80).

Inspectors wroteBased on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure the advanced directives were accurately reflected in residents' records for one of 30 residents reviewed (Resident 79).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined the facility failed to ensure a baseline care plan was developed for one of the 30 residents reviewed (Resident 110).

Inspectors wroteBased on clinical record review, it was determined that the facility failed to ensure residents had comprehensive care plans for one of 26 residents reviewed (Resident 113).

Inspectors wroteBased on clinical record review and facility documentation, it was determined the facility failed to ensure one of two residents reviewed for elopement was provided adequate supervision to prevent elopement (Resident 113).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to provide care and services related to catheter care for one of five residents reviewed. (Resident 90) Findings Include: Review of Resident 90's physician orders revealed an order dated January 16, 2024 to perform indwelling catheter care every day and night shift. The physician's order was discontinued on April 17, 2024. Observation of Resident 90 on July 15, 2024 at 9:30 a.m. revealed Resident 90 had an indwelling catheter. Review of resident 90's clinical record revealed there was no documented evidence Resident 90 had been receiving catheter care since April 17, 2024 when the order for care was discontinued. Interview with the Director of Nursing on July 18, 2024 at 11:30 a.m. [...]

Inspectors wroteBased on clinical records review and staff interviews, it was determined that the facility failed to ensure injury of unknown cause was comprehensively investigated for one two residents reviewed (Resident 1)

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to follow a physician's order regarding vital signs monitoring and failed to notify the physician of an x-ray result timely for one of the two residents reviewed (Resident1).

Inspectors wroteBased on review of facility policy, facility investigative documentation, clinical and hospital records, it was determined that the facility failed to ensure one of 24 residents was free from neglect, which resulted in actual harm to Resident 120, through Employee E3's failure to report a fall to registered nurse, the resident experienced a delay in assessment, treatment, and subsequent hospitalization for intracranial hemorrhage (brain bleed) resulting in death.

Inspectors wroteBased on review of the facility's policy, clinical record reviews, and staff interviews, it was determined that the facility failed to monitor and provide wound treatment timely and consistently resulting in harm of a new pressure ulcer discovered at an advanced stage (Stage 3- Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue) for one of nine residents reviewed (Resident 54).

Inspectors wroteBased on observation, and staff interviews, it was determined that the facility failed to maintain, and prepare food by professional standards and maintain sanitary conditions in the kitchen area.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure accurate assessments for one of 24 residents reviewed (Resident 38).

Inspectors wroteBased on clinical record review, facility policy and procedure review, facility documentation review and staff interview it was determined the facility failed to provide sufficient supervision to prevent an accident for one of 24 residents reviewed. (Resident 96) Findings Include: Review of facility policy and procedure titled Safe Resident Handling/Transfer Equipment, effective January 1, 2023, revealed Patients will be assessed upon admission and on an ongoing basis to determine the patient's ability to transfer and reposition and the need for safe resident handling equipment. Two trained persons are required to operate a total lift or sit to stand lift regardless if manufacturers instructions state only one person is needed. [...]

Inspectors wroteBased on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to assess the resident's continence status after identifying a change for one of the 24 residents reviewed (Resident 61).