The Belmont at Twin Creeks

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 three of six residents (Residents #2, #3, and #4) reviewed for respiratory care. 1. The facility failed to ensure Resident #2's BiPAP (bilevel positive airway pressure: normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) mask was properly stored when not in use on 05/29/2026.2. The facility failed to ensure Resident #3's CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) mask was properly stored when not in use on 05/29/2026.3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for three of ten residents (Residents #2, #5, and #6) reviewed for labelling of drugs and biologicals.1. The facility failed to ensure Resident #2's zinc oxide (a form of barrier cream used to treat skin irritations, diaper rash, and other skin conditions) was not left on top of the resident's overbed table on 05/29/2026.2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care and confidentiality of personal and medical records for one of five residents (Residents #1) reviewed for privacy and confidentiality. The facility failed to ensure Resident #1's pharmacy slip, with his name and the name of his medication on it, was not left at the ledge of the nurse's station on 05/29/2026. This failure could place the residents at risk of having their personal and medical record exposed to unauthorized individuals.

Inspectors wroteBased 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, lack of care plan interventions, and physician orders for oxygen administration for four of twelve residents (Residents #2, #3, #4 and #5) reviewed for respiratory care. 1. The facility failed to ensure Resident #2 had her nebulizer mask and nasal cannula bagged when not in use on 04/21/26. 2. The facility failed to ensure Resident #3's nasal cannula, connected to the oxygen concentrator, (medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen) was properly stored on 04/21/26. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 6 of 8 (Residents #4, #6, #7, #8, #9, and #10) reviewed for medication storage. 1. The facility failed to ensure Resident #6 did not have a pink paste (moisture barrier cream) inside the room on [DATE]. 2. The facility failed to ensure a white powder (Nystatin) was not inside Resident #7's room on [DATE]. 3. The facility failed to ensure Resident #8 did not have a pink paste (moisture barrier cream) inside the room on [DATE]. 4. The facility failed to ensure Resident #9 did not have a Topical anesthetic spray and pink paste (moisture barrier cream) inside the room on [DATE] 5. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident #1) reviewed for privacy and confidentiality. The facility failed to ensure Resident #1's medication prescription was not left on top of the medication cart on 04/21/26. This failure could place residents at risk of not having their personal privacy maintained while care was provided and their personal and medical record exposed to unauthorized individuals.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from chemical restraints that were not required to treat the residents' medical symptoms for 1 (Resident #89) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #89's PRN prescription of Xanax 0.5mg (a medication used to treat the symptoms of anxiety) was discontinued after 14 days. The facility did not document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for 1 of (Resident #71) of 3 residents reviewed for discharge planning. The facility failed to complete a recapitulation of stay for Resident #71, who discharged to another facility on 05/06/25. This failure could place residents at risk of a recapitulation of their stay being unavailable to help ensure continuity of care once they discharged from the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure they offered a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for 1 of 3 residents (Resident #27) reviewed for nutritional status. The facility failed to ensure Resident #27 received the therapeutic diet that was ordered for her during the lunch hour on 05/20/25. This failure could result in residents not receiving their ordered therapeutic meal which could lead to malnutrition and/or choking.

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 (Resident #73) of four residents reviewed for pharmacy services. The facility failed to ensure the medication cart contained accurate narcotic logs for Resident #73. This failure could place residents at risk for medication error and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #73) of four residents reviewed for medication errors. The facility failed to ensure morphine (pain medicine) was administered to Resident #73 as ordered from 05/11/25 until 05/18/25 and 05/20/25. (9 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 observations, interviews, 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 two (Resident #57 and Resident #84) of eight residents, reviewed for infection control. 1. The facility failed to ensure CNA G performed hand hygiene during incontinence care and did not soil the wipes container with soiled gloves for Resident #57. 2. The facility failed to ensure CNA H did not soil the wipes container with soiled gloves for Resident #84. This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the right to be free from abuse was provided for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. The facility failed to protect Resident #1 from abuse when CNA A was witnessed being verbally and physically abusive to Resident #1, resulting in Resident #1 becoming fearful of CNA A. The noncompliance was identified as PNC. The noncompliance began on 12/23/24 and ended on 12/27/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received routine and 24-hour emergency dental services for one of (Residents #2) of three residents reviewed for the provision of routine/emergency dental services. The facility failed to ensure Resident #2 received routine dental care. This failure could affect residents by placing them at risk of pain, weight loss, infection, difficulty eating and a decline in their quality of life due to unmet dental needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were immediately reported, including injuries of unknown origin, but not later than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury 24 hours after the allegations were made, to the State Survey Agency for one (Resident #1) of six residents reviewed for abuse. 1. Facility staff (CNA B) failed to notify the Abuse Coordinator/ADM of witnessed abuse of Resident #1 by CNA A. 2. The Abuse Coordinator failed to report to the State Survey Agency alleged abuse when Resident #1 reported abuse to facility staff on 12/09/2024. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for one (Resident #1) of four residents reviewed for foot care. The facility failed to ensure Resident #1 received foot care. This failure could place residents at risk of diminished quality of life by not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, 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 1 of 2 Residents (Resident #1) reviewed for medication administration. Resident #1 received medication (Oxybutynin and Trazodone) on 06/22/2024 that was prescribed for another resident. The noncompliance was identified as PNC. The noncompliance began on 06/22/2024 and ended on 06/22/2024. The facility had corrected the noncompliance before the survey on 07/06/2024. This deficient practice could affect resident who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, and comfortable environment for 2 of 7 (Resident #4 and #5) residents reviewed for resident rights. The facility failed to ensure Resident #4's room, which shared a bathroom with Resident #5's room, was clean and free of urine odors. This failure could place residents at risk of living in an unsanitary, unclean environment which could diminish their quality of life.

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 2 (Residents #2 and #8) of 4 residents reviewed for incontinence care. CNA A and CNA B failed to perform hand hygiene during incontinence care for Resident #2 and Resident #8. These failures placed all residents at risk of unintended infections and inadequate treatment.

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 only kitchen. The facility failed to ensure foods were properly stored, labeled, and expired foods were discarded. This failure could have affected 83 of the 87 residents at the facility by placing them at risk for food exposed to adulteration or contaminantes. Adulterated foods have had severe health effects. Diarrhea, nausea, allergic reactions, diabetes, and cardiovascular disease have been observed upon consumption of adulterated food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all allegations of abuse were reported immediately to the State agency, thoroughly investigated, and residents were protected during investigation for 1 of 5 residents reviewed for abuse and neglect. (Resident #34). The facility failed to report immediately to the State agency when Resident #34 was found alone on the floor in her room. These failures could place residents at risk for not having allegations of abuse investigated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 3 residents (Resident #95) reviewed for PASRR Level I screenings. The facility did not correctly identify Resident #95 as having a mental illness and did not complete a new PASRR Level I Screening. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan 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 for 1 (Resident #95) of 3 residents reviewed for baseline care plans, in that: The facility failed to ensure Resident #95's baseline care plan was completed and included information related to her care needs and status at the time of her admission. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met.

Inspectors wroteBased on observation, interviews and record review the facility failed to develop and implement a comprehensive person care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for two of eight residents reviewed for care plans. (Residents #08 and #35). The facility failed to develop and implement person-centered care plans for Residents #08 and #35. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and a decline in physical well-being. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities for one resident (Resident #51) of 2 residents reviewed for enteral nutrition. LVN E failed to check for residual volume prior to medication administration for Resident #51 These failures could affect all residents who receive enteral feeding and place them at risk for metabolic abnormalities, medical complications, or a decline in health due to not following appropriate procedures.

Inspectors wroteBased on interview and record review the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 (Resident #250) residents reviewed for parenteral fluids. The facility did not ensure Resident #250's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed per the physician's order. This failure could place residents at risk for receiving care that is not safe and meets professional care standards. Findings Included: Record review of the face sheet dated 03/22/24 indicated Resident #250 was a [AGE] year-old female who discharged from the facility on 02/12/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received food that accommodates resident preferences for one resident (Resident #21) of five residents reviewed for food preferences. The facility failed to ensure Resident #21's likes and dislikes food preferences were honored during the lunch service on 02/06/23. This failure could cause residents who ate meals from the kitchen at risk of not having their choices and food preferences accommodated, possible weight loss, and a diminished quality of life.