Gardens of Belden Village

Inspectors wroteBased on observation and interview, the facility failed to dispose of expired foods in a timely manner which resulted in expired food being served to residents. This had the potential to affect all 80 residents that received food from the kitchen. The facility census was 80.

Inspectors wroteBased on observation and interview, the facility failed to ensure the laundry cart used to transport clean clothing/linens from the washing machines to the dryers did not have water dripping into them from a leak in the ceiling. This had the potential to affect all 80 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, hospital record review, review of guidance from the American Diabetes Association (ADA), review of guidance from the Centers for Disease Control and Prevention (CDC), review of guidance from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), review of guidance from the National Institutes of Health (NIH) and National Library of Medicine's MedlinePlus information, facility policy review and interviews, the facility failed to adequately monitor Resident #42's diabetes; failed to ensure medications were available for Resident #99's use; failed to ensure adequate indication for blood sugar testing (finger sticks) for Resident #33; failed to ensure skin assessments and treatments were in place for Residents #27, #35 and #62; failed to ensure testing instructions were followed for Resident #7; [...]

Inspectors wroteBased on record review, observation, facility policy review and interview, the facility failed to ensure Residents #64 and #66 were provided with dignity during meals. This finding affected two (Residents #64 and #66) of five residents reviewed for dignity and respect during meals. The facility census was 80.

Inspectors wroteBased on record review and interview, the facility failed to implement a comprehensive care plan with relevant interventions for Resident #77. This affected one (Resident #77) out of one resident reviewed for elopement. The facility census was 80.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan to accurately reflect the status of Resident #26. This affected one (Resident #26) out of three residents reviewed for catheter use. The facility census was 80.

Inspectors wroteBased on record review, observation, facility policy review and interview, the facility failed to ensure Resident #64's eyes were free of debris and Resident #26 received showers as scheduled. This finding affected two (Residents #26 and #64) of four residents reviewed for activities of daily living (ADL). The facility census was 80.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure Resident #1's oxygen tubing was stored in the proper manner when not in use. This affected one (Resident #1) out of one reviewed for respiratory care. The facility census 80.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident #1's oxygen tubing was stored in the proper manner when not in use. This affected one (Resident #1) out of one reviewed for respiratory care. The facility census was 80.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure Resident #100 had pain medication available. This affected one (Resident #100) out of six residents reviewed for pain management. The facility census was 80.

Inspectors wroteBased on record review and interviews, the facility failed to monitor and maintain adequate communication with the outside dialysis center to include vital signs and weights before and after dialysis and failed to ensure the facility had a dialysis policy. This affected one (Resident #7) of one resident reviewed for dialysis. The facility identified Resident #7 as the only resident receiving dialysis in the facility. The facility census was 80.

Inspectors wroteBased on record review, review of the American Diabetes Association's (ADA's) information on A1C and estimated average glucose (eAG), review of the facility policy and interview, the facility failed to ensure the physician provided comprehensive care for Resident #42. This affected one (Resident #42) out of three residents reviewed for physician's services. The facility census was 80.

Inspectors wroteBased on record review and interview, the facility failed to ensure individual patient-controlled substance administration records and medication administration records were accurate for Resident #99. This affected one (Resident #99) out of six residents reviewed for unnecessary medications. The facility census was 80.

Inspectors wroteBased on record review, review of the McGreer Criteria and interview, the facility failed to ensure Resident #33 did not receive unnecessary antibiotics. This affected one (Resident #33) out of six residents reviewed for unnecessary medications. The facility census was 80.

Inspectors wroteBased on record review, interviews, review of photos and facility policy review, the facility failed to ensure medications were not left at bedside of Resident #7. This affected one (Resident #7) of one resident reviewed for unsecured medications. The facility census was 80.

Inspectors wroteBased on record review, facility policy review and interview, the facility failed to ensure Resident #7's medical record was accurate and complete. This finding affected one (Resident #7) of three residents reviewed for accuracy of medical records. The facility census was 80.

Inspectors wroteBased on record review, observation, facility policy review and interview, the facility failed to implement personal protective equipment (PPE) as required during care of Residents #45 and #62 who were in contact isolation precautions. The facility also failed to put the correct infection control precautions in place when Resident #62 was admitted . This finding affected two (Residents #45 and #62) of three residents reviewed for contact isolation precautions. The facility census was 80.

Inspectors wroteBased on record review, interview, facility self-reported incident (SRI) review, police report review, and facility policy review, the facility failed to ensure Resident #77 was free from sexual abuse. This affected one resident (Resident #77) of three residents reviewed for abuse.

Inspectors wroteBased on record review, interview, facility self-reported incident (SRI) review, police report, and facility policy review, the facility failed to thoroughly investigate a sexual abuse allegation for Resident #77. This affected one resident (Resident #77) out of three residents reviewed for abuse. The facility census was 92.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure am individualized comprehensive nutrition plan was in place for Resident #5 and Resident #95 to properly monitor weights, nutritional status, and treat weight loss properly. This affected two residents (Resident #5 and #95) out of three residents reviewed for weights. Facility census was 92.

Inspectors wroteBased on resident interview, staff interview, family interview, record review, and policy review, the facility failed to provide timely care and services to Resident #34 when she experienced a change of condition in the facility. This affected one resident (#34) out of three residents reviewed for change of condition. The facility census was 90.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to ensure effective measures/systems were in place to prevent resident falls with injury. The facility failed to ensure Resident #38 was transferred appropriately using a gait belt and failed to ensure Resident #48's bed U-bar side rail was maintained in good repair. This affected two residents (#38 and #48) of four residents reviewed for accidents and hazards. Actual harm occurred on 09/25/24 at 9:40 A.M. to Resident #38, when Certified Nursing Assistant (CNA) #831 attempted to transfer Resident #38 from a bedside commode to the wheelchair without using a gait belt as care planned. Resident #38 and STNA #831 fell to the floor. Resident #38 sustained a fractured hip which required surgical repair and had chronic pain post surgical repair. Actual harm occurred on 06/08/24 at 3:47 P.M. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the kitchen was maintained in a sanitary manner, foods were dated, labeled, and discarded when expired, and ensure the ware washing was completed appropriately to ensure sanitation. This affected all 87 residents receiving meals from the kitchen. The facility indicated there were no residents who received nothing by mouth. The facility census was 87.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the appropriate use of personal protective equipment. This had the potential to affect 47 residents who resided on the second floor including Residents #1, #4, #6, #9, #11, #12, #13, #16, #19, #20, #22, #24, #27, #28, #29, #30, #34, #36, #38, #39, #40, #41, #42, #44, #51, #52, #55, #56, #57, #58, #61, #65, #70, #71, #74, #75, #76, #77, #78, #79, #80, #81, #84, #137, #187, #189 and #190. The facility census was 87.

Inspectors wroteBased on observation, interview, facility repair invoice and facility policy, the facility failed to ensure repairs were completed timely following identified concerns. This affected three residents ( #48, #59 and #69) of seven ( #7, #16, #48, #59, #69, #84 and #137) reviewed for environmental concerns requiring repairs. The facility census was 87.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #13. This affected one resident (#13) of one reviewed for dialysis. The facility census was 87.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure perineal care was performed appropriately after an episode of urinary and bowel incontinence. This affected one (Resident #81) of one resident observed for incontinence care. The facility census was 81.

Inspectors wroteBased on closed medical record review, electronic communication document review, staff interview, and non-facility staff interview, the facility failed to ensure all discharge records were completed timely so residents who were discharged could fully use their insurance benefits. This affected one resident (#81) of three resident records reviewed. The facility census was 79. Findings Include: Review of the closed medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, low back pain, chronic viral hepatitis, paranoid schizophrenia, anxiety disorder, other recurrent depressive disorder, neuromuscular dysfunction of bladder, neurogenic bowel, muscle weakness, adult failure to thrive, chronic pain syndrome, and other psychoactive substance abuse. [...]

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to inform residents of new orders and treatment plans. This affected one (Resident #36) of three residents reviewed for change in condition. The facility census was 76.

Inspectors wroteBased on review of the medical record , review of the Self-Reported Incident (SRI), interview with staff and review of the facility policy the facility failed to prevent misappropriation of resident narcotics. This affected one resident (R#9) of three residents reviewed for narcotic medication use. The facility census was 75.

Inspectors wroteBased on review of the medical record and interview with staff the facility failed to provide timely diagnostic testing and treatment of a resident with an urinary tract infection. This affected one resident (#56) of three reviewed for infection control. The facility census was 75.

Inspectors wroteBased on review of the medical record and staff interview the facility failed to ensure a resident was free of a significant medication error. This affected one resident (#20) of three reviewed for medication administration.

Inspectors wroteBased upon interview and record review, the facility staff failed to treat all Residents with dignity and respect at all times. This affected two Residents (#53 and #71) of 30 residents interviewed for dignity and respect. The facility census was 71.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were disbursed within 30 days of discharge for Resident #124. This affected one of one residents reviewed for closed resident fund accounts. The facility census was 71.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure Residents #17 and #54 received showers/baths as scheduled. This affected two (#17 and #54) of three residents reviewed for bathing. The census was 71.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Residents # 11, #66, and #123 were appropriately supervised while smoking cigarettes and in accordance with the smoking policy. This affected three residents of 18 residents the facility identified as smokers. The facility census was 71.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 71.