Helia Southbelt Healthcare

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call lights, preferences and needs were reasonably accommodated for 4 of 13 residents (R1, R2, R5 and R8) reviewed for accommodation of needs in a sample of 13. 1- On 7/2/2026 at 2:02 PM, R1 has a tracheotomy in his neck. R1 was laying on his back in his bed. On 7/2/2026 at 2:05 PM, R1 stated, I am bed bound, and call lights vary depending on who is working. Sometimes it is better than other times. I think the night shift is the worst. It is not uncommon for us to have to wait. Staff are bad about coming into the room, turning off the light, and not coming back. R1's Minimum Data Set provided by the facility dated 3/13/2026 does not document R1's cognitive status. The MDS does document R1 is able to make decisions regarding tasks of daily life and his decision are consistent/reasonable. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate written notification was provided for a room change for 4 of 4 residents (R2, R6, R9 and R12) reviewed for resident rights.

Inspectors wroteBased on interviews and record review, the facility failed to properly secure a resident's wheelchair in the transport van during transport for 1 (R2) of 3 residents reviewed for accidents in the sample of 16. This failure resulted in R2 falling from her wheelchair while the van was in motion, sustaining multiple serious injuries: a periprosthetic proximal femur fracture, intertrochanteric fracture of the left femur, distal fracture of the right femur, nasal fracture, and a scalp laceration. R2 required surgical fixation of the right femur (open reduction internal fixation) and suturing of the forehead laceration. An Immediate Jeopardy began on 4/24/26 when R2 was being transported to doctor's appointment in the facility van. [...]

Inspectors wroteBased on interview and record review the facility failed to revise and update a comprehensive care plan for 2 of 3 (R2, R3) residents investigated for pressure ulcers in a sample of 16.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to store and prepare food in a manner that prevents potential contamination. This has the potential to affect all 94 residents living in the Facility.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's representative and physician of a change in condition in 1 of 3 residents (R7), reviewed for notifications of changes in the sample of 3. Findings Include:On 3/24/26 at 9:20 AM, V7, R7's Family, stated after R7 passed away they received a bill from a wound care company that had seen R7 for a wound and something was removed, the family was not notified of any wounds and didn't know about it until they received a bill. V7 stated they did not notify the family that R7 had been removing her tracheostomy tube, and the communication was horrible. R7's Face Sheet, undated, documents R7 had the following diagnoses: Intracerebral Hemorrhage, Anxiety Disorder, Unspecified Dementia, Tracheostomy Status, Acute Respiratory Failure, and Depression. V7 is listed as R7's emergency contact and power of attorney. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement preventative measures for a resident with a known history of attempting self extubation of the tracheostomy tube in 1 of 3 residents (R7), reviewed for respiratory/tracheostomy care in the sample of 13. Findings Include: On 3/24/26 at 9:20 AM, V7, R7's Family, stated R7 was admitted to the facility from another state, it was a disaster from when she was admitted until she passed away. R7 pulled out her tracheostomy tube on several occasions. V7 stated they did not notify the family that R7 had been removing her tracheostomy tube, and the communication was horrible. R7's Face Sheet, undated, documents R7 had the following diagnoses: Intracerebral Hemorrhage, Anxiety Disorder, Unspecified Dementia, Tracheostomy Status, Acute Respiratory Failure, and Depression. R7 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the Facility failed to ensure residents only smoke in designated, safe areas and tobacco and smoking supplies are kept in secure locations for 1 of 3 residents (R2) reviewed for accidents and hazards in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for hand contracture management and treatment for 1 of 1 resident (R34) reviewed for quality of care in the sample of 57. This failure resulted in R34 experiencing severe pain, infection, and a wound on her left hand. Findings Include: R34's face sheet, print date of 9/23/25, documented R34 has diagnoses including atherosclerotic heart disease, hypothyroidism, type 2 diabetes mellitus, hyperlipidemia, major depressive disorder, anxiety disorder, intermittent asthma, and muscle weakness. R34's MDS (Minimum Data Set), dated 7/4/25, documented R34 is moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medication and label insulin vials. This has the potential to affect all 89 residents residing in the facility.

Inspectors wroteBased on interviews, observation and record reviews the facility failed to serve food that conserved nutritive value, flavor and safe appetizing temperature for 5 out of 5 residents, (R17, R11, R43, R71 and R73); reviewed for Food and Nutrition Services in a sample size of 57.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clean sanitary conditions in the kitchen, food was labeled, dated correctly, removed from the walk-in refrigerator as indicated, and perform proper hand hygiene during food service. This failure has the potential to affect all the residents who receive food from the kitchen. Findings Include:On 09/22/2025 at 8:50 AM, Initial tour of the kitchen was done. This surveyor washed her hands prior to inspection started and there were no paper towels in the dispenser. The sink where employees wash their hands was dirty. There was dirt and a slimy film and rust around the faucet on the sink. [...]

Inspectors wroteBased on interviews, observations and record reviews the facility failed to perform hand hygiene for 5 out of 5 residents, (R39, R28, R53, R81, R82); reviewed for Infection Control in a sample size of.

Inspectors wroteBased on interviews, observation and record reviews the facility failed to promote respect and dignity for 1 out of 1 residents, (R64); reviewed for in Resident Rights in a sample size of 57.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for 3 of 7 residents (R34, R44, R76) reviewed for care plans in a sample of 57.

Inspectors wroteBased on observation, interview, and record review the facility failed properly and safely transfer 2 of 5 residents (R45 and R30) reviewed for safety in a sample of 57. This failure resulted in R30's leg being hit on the mechanical lift and experienced pain.

Inspectors wroteBased on observation, interview and record review the facility failed to perform complete incontinence care for 1 of 3 (R30) residents reviewed for toileting in a sample of 57.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 3 residents (R9) reviewed for abuse in a sample of 3. Findings Include:R9's Face Sheet, undated, documents R9 was admitted to the facility on [DATE] and has a medical diagnosis of Psychoactive Substance Abuse, Blindness Right Eye Category 3, Blindness Left Eye Category 3, and Hallucinations. R9's Minimum Data Set (MDS) dated [DATE] documents R9 is moderately cognitively impaired and has displayed verbal behaviors directed towards others. R9's Care Plan R9's Care Plan Last Reviewed/ Revised 8/18/2025 documents resident is considered at risk for abuse/neglect. R9's Progress Note dated 9/8/2025 at 6:05 PM documents This resident had an altercation with another resident related to resident hitting him in the groin. Then resident started slapping other resident in the face. [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure residents requiring assistance for transfers were getting assistance and transferred with the mechanical lift for 1 of 3 residents reviewed for transfers in the sample of 11.

Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent resident to resident abuse for 1 of 6 residents (R3) reviewed for abuse in the sample of 8. This failure resulted in R3 having lacerations and bruising. Findings Include:On 8/13/25 at 1:00 PM, R3 was observed ambulating independently on the hallway he resides. R3 was wandering on the hallway, stopping at various doors but did not enter. R3 was alert to self only. R3's Face Sheet, undated, documents R3 has the following diagnoses: Dementia, Restless and Agitation, Unspecified Psychosis, Major Depressive Disorder, Generalized Anxiety Disorder, and Insomnia. R3's Minimum Data Set, MDS, dated [DATE], documents R3 has a BIMS (Brief Interview of Mental Status) score of 2, indicating R3 has severe cognitive impairment. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to adequately assess and provide supervision to prevent elopement for 1 of 5 residents (R7) reviewed for supervision in the sample of 8. Findings Include:On 8/13/25 at 11:00AM, R7 observed up in his electric wheelchair exiting the facility through the front door. R7 was able to enter the code and stayed in front of the facility. R7's Face Sheet, undated, documents R7 has the following diagnoses: Hemiplegia and Hemiparesis following a Cerebrovascular Disease Affecting the Left Non-Dominant Side, Cerebral Infarction, Vascular Dementia, and Acquired Absence Below the Knee of Right and Left Legs. R7's Minimum Data Set, MDS, dated [DATE], documents R7 has a BIMS (Brief Interview of Mental Status) score of 12, indicating R7 has moderate cognitive impairment. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide revise interventions/approaches for behaviors in a resident with Dementia related to wandering for 1 of 1 resident (R3), reviewed for Dementia Care in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to notify the responsible party of a change in condition for 1 out of 3 residents, (R4); reviewed for Resident Rights in a sample of 11.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure medications were completely administered and failed to accurately document the administration of medications for 1 out of 4 residents, (R2) reviewed for Pharmacy Services in a sample of 11.

Inspectors wroteBased on interview and record review the facility failed to prevent physical and verbal abuse for 1 of 3 (R2) residents investigated for abuse.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent urinary tract infections for 3 of 4 residents (R3, R4, R5) reviewed for incontinent care in the sample of 8.

Inspectors wroteBased on record review and interview the facility failed to ensure 1 of 3 resident's (R6) prescription eye drops were documented as administered per professional standards regarding medication administration/documentation in a sample of 3.

Inspectors wroteBased on observation, record review and interview the facility failed to use a gait belt during a one person transfer, and failed to implement fall precautions for 2 of 2 residents (R7, R11) in a sample of 21 reviewed for falls.

Inspectors wroteBased on interview and record review, the Facility failed to provide timely and reliable transportation for medical care for 1 of 3 residents (R2) reviewed for provision of medically related social services in the sample of 21.

Inspectors wroteBased on record review and interview the facility failed to ensure 1 of 3 residents (R6) medication were refilled by the pharmacy or delivered to the facility for prescribed eye drops regarding medications per physician's orders in a sample of 3.

Inspectors wroteBased on record review and interview the facility failed to ensure 1 of 3 residents (R6) medication administration record was accurately documented for physician prescribed eye drops regarding documentation of medication administration in a sample of 3.

Inspectors wroteBased on interview and record review, the Facility failed to ensure residents were free from abuse for 1 of 3 residents (R2) reviewed for physical abuse in the sample of 3.

Inspectors wroteBased on records review and interviews, the facility failed to permit a resident to return to the facility from the hospital for 1 of 3 (R5) residents reviewed for discharge in a sample of 11.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to apply residents' continuous positive airway pressure (C-PAP)/bilevel positive airway pressure (Bi-PAP) machine at bedtime as ordered for 1 of 2 residents (R3) reviewed for respiratory care in a sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to complete an updated facility assessment to accurately reflect their current resident acuity levels and population. This failure has the potential to affect all 104 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse in 5 of 5 residents (R34, R53, R63, R67, R77,) reviewed for abuse in the sample of 43.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide activities for 4 of 4 residents (R34, R57, R72, R77), reviewed for activities in the sample of 43.

Inspectors wroteBased on interview and observation the facility failed to hold and serve food at safe temperatures for therapeutic diets for 7 out of 7 residents (R25, R47, R54, R66, R88, R90, and R92) reviewed for food procurement store/prepare/serve food in the sample of 43. Findings Include: R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact. R25 stated during the group meeting on 8/8/24 at 2:00 PM that the food is always cold for breakfast. R47's MDS dated [DATE] documents R47 is cognitively intact. During the group meeting on 8/8/24 at 2:00PM R47 stated that the food is always cold at breakfast. R92's MDS dated [DATE] documents R92 is cognitively intact. On 8/8/24 at 2:00PM in the group R92 stated the food is always cold at breakfast. R54's Physician Order Sheet (POS) dated 1/28/24 documents that R54 is on a regular diet mechanical soft. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to provide wound care treatments as ordered by the Physician to promote wound healing in 1 of 4 residents (R2) reviewed for quality of care in the sample of 7.

Inspectors wroteBased on interview, observation and record review, the facility failed to infuse tube feeding at a rate ordered by the physician to aid in nutrition in 1 of 4 residents (R4) reviewed for tube feeding management in the sample of 7.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide and implement fall interventions as care planned for 4 of 5 (R1, R2, R4, R5) residents reviewed for accidents. R1's face sheet, print date 7/3/24, documented R1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, epileptic seizures, heart disease, type 2 diabetes mellitus, and depression. R1's MDS (Minimum Data Set), dated 5/10/24, documented that R1 is cognitively intact. R1's care plan, undated, documented that R1 is at risk for falls related to an unsteady gait and that R1 is to have the following interventions in place: reminder signs placed to remind to use call light for assistance, canoe mattress on bed, and dycem in her wheelchair to prevent sliding. [...]

Inspectors wroteBased on interview and record review the facility failed to provide insulin for the first five days of admission for one of three residents( R2) reviewed for significant medications errors in the sample of 9. Findings Include: R2's Minimum Data Set, dated [DATE] documents R2 is moderately cognitively impaired. R2's Electronic Health Record under CCD (Continuity of Care) Diagnosis documents Type 2 Diabetes without complications was added on 5/13/24. R2's Face Sheet documents R2 was admitted on [DATE]. R2's admission Note dated 5/13/24 resident admitted to facility via family transportation from (Another State). resident present A&Ox2-3 (Alert and Oriented). Resident in good spirit with minor confusion on where he is. Resident currently has on a back brace related to recent fall and sustained T12 fracture as well as 11th and 12th rib fracture per family and referral paperwork. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to take and record food temperatures before and during meal service, to maintain food at the proper temperatures when delivering meals to the residents, and to perform glove changes and hand hygiene during serving of the food. This has the potential to affect all 114 residents residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to make sure medications were provided and given for 1 of 3 residents, (R2) reviewed for significant medications in the sample of 18. This failure resulted in R2 missing, 9 doses of his Glaucoma medication, which is a significant medication error. Findings Include: R2's Minimum Data Set, (MDS), dated [DATE] documents, R2 is severely cognitively impaired. R2's Care Plan dated, 05/03/23, did not document anything about his Glaucoma, for bedside usage of Glaucoma medications. R2's Physician Order Sheet, (POS), dated 11/08/23, documents, Brimonidine/Timolol 0.2%-0.5% BID, (Twice Daily), may have drops at bedside, for resident to insert. R2's POS dated, 02/19/24, documents, Brimonidine/Timolol 0.2%-0.5%), May have drops at bedside, Pharmacy last filled on 02/03/24. [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure resident showers for activities of daily living were being given for 5 of 8 residents (R2, R3, R5, R7 and R8) reviewed for activities of daily living to maintain good grooming and personal hygiene in the sample of 10.

Inspectors wroteBased on interview and record review the Facility failed to ensure Physician Orders were being followed and residents were free from any significant medication errors for 1 of 6 residents (R2) reviewed for medication errors in the sample of 24. This failure resulted in R2 not receiving her medications and being hospitalized for six days with a diagnosis of urinary tract infection and urosepsis.

Inspectors wroteBased on interview and record review the Facility failed to ensure showers were being given for 7 of 8 residents (R3, R6, R7, R8, R9, R10, R11) reviewed for showers in the sample of 24.

Inspectors wroteBased on interview, and record review, the facility failed to supervise a resident that is a high risk fall falls while toileting for 1 of 3 (R7) residents reviewed for falls in the sample of 9. This failure resulted in R7 falling and sustaining a fracture to T12. Findings Include: R7's Face Sheet documents an admission date of 11/8/2023. Diagnosis to include Acute Coronary Thrombosis not resulting in Myocardial Infarction, Vitamin B12 Deficiency Anemia due to intrinsic factor deficiency, Transient ischemic Attack (TIA), and Cerebral Infarction without residual deficits, Weakness, Pain in Left Leg and Hypertension. R7's care plan dated 11/12/2023 documents R7 is new to facility and needs time to acclimate to facility life, favorite act. is playing bingo. Interventions include: Inform R7 of upcoming activities by: provide activity calendar, verbal reminders, encouragement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform timely incontinent care for 2 of 3 residents (R1, R2,) reviewed for Activities of Daily living in the sample of 9. Findings Include: 1. R1's Face Sheet documents an admission date of 3/30/2022. Diagnosis includes: History of Malignant Neoplasm to Bladder, Right Below the Knee Amputation, Chronic Kidney Disease, Atherosclerotic Heart Disease, Peripheral Vascular Disease On 11/16/2023 at 11:40AM, R1 stated to V3 CNA and V4 LPN that she was dirty with a bowel movement (BM). V3 nor V4, did not do incontinent care while in room. At 12:00PM V7, CNA, completed incontinent care to R1. No issues noted. R1's Minimum Data Set, MDS, dated [DATE] documents R1 has no cognitive impairments and is frequently incontinent of bowels. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ostomy care consistent with professional standards of practice for 2 of 2 residents (R1, R4) reviewed for ostomy care in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician for 1 of 6 residents (R3) reviewed for pharmacy services in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to provide showers to residents on a twice weekly basis for 4 of 4 (R1, R2, R3, R41) residents in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to perform safe transfers for 1 of 10 residents (R86) reviewed for falls in the sample of 45. This failure resulted in R86 sustaining a head laceration that required five staples in the emergency room (ER).

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store, prepare, and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 97 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop an ongoing infection control surveillance program. This has the potential to affect all 97 residents living in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to prevent resident-to-resident abuse for 6 of 6 residents (R6, R18, R20, R52, R74, R79) reviewed for resident-to-resident abuse in the sample of 45.

Inspectors wroteBased on interview and record review the facility failed to provide showers to residents on a twice weekly basis for 7 of 7 (R86, R33, R303, R31, R70, R41, R21) residents in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with limited range of motion (ROM) receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 4 out of 4 (R10, R45, R66, R81) residents in a sample of 45 investigated for contractures.

Inspectors wroteBased on interview and record review the facility failed to report a resident-to-resident altercation for 1 of 5 residents (R52) reviewed for resident-to-resident altercations in the sample of 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely tube feedings for one of one resident (R45) reviewed for tube feedings in the sample of 45. Findings Include: R45 Care Plan dated 4/19/23 (R45) requires nutrition through g-tube. NPO, (Nothing by Mouth). Receives Tube feeding as ordered. Tube placement checks per auscultation before meals. All medications given through g-tube per order. H2O (water) flush as recommended 1/5/22 enteral feeding per MD (Medical Doctor) order for 15hrs daily. R45's Minimum Data Set, dated [DATE] documents, R45 is cognitively intact. R45's Physician Order Sheet dated 5/16/23 documents, tube feeding Nutren 1.5 80 ml (milliliters), per hour from 3 PM to 6 AM. On 7/13/23 at 3:00 PM, there was a bag of clear liquid hanging on a tube feeding pole labeled 7/13 at 8 AM. No enteral feeding product was hanging. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that include antibiotic use protocols in 2 of 2 residents (R17, R94) reviewed for antibiotic stewardship in the sample of 45.