Belvedere Nursing And Rehabilitation Center, LLC

Based on observations, interview, record review, and facility policy review, it was determined the facility failed to have adequate interventions in the resident's care plan, for non-compliant behaviors, with a resident with a history of nicotine dependence (Resident #9) out of 4 residents reviewed for accidents and adequate individualized care plans.Based on observations, interview, record review, and facility policy review, it was determined that the facility failed to develop and implement a comprehensive care plan for one (Resident #9) out of four residents reviewed. Specifically, to ensure the resident's care plan addressed non-compliant behaviors related to a history of nicotine dependence and bringing electronic cigarettes (vapes) into the facility. The findings include: Review of Resident #9's admission Record revealed the facility admitted Resident #9 on 03/17/2026 with diagnoses which included malignant neoplasm of the brain, anxiety, pneumonia, and nicotine dependence with withdrawal. Review of Resident #9's admission Minimum Data Set (MDS) with an Assessment Reference…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview, and facility record review, the facility failed to ensure the central bath and soiled utility room on 300 Hall were locked to prevent resident access to dirty linens, chemicals, and wet floors to prevent accidents and injuries. The facility failed to ensure the mechanical lift was in good working order to prevent accidents and injuries to 1 (Resident #49) of 1 sampled resident reviewed for accidents and injuries. Findings include: 1. a. On 11/04/24 at 10:34 AM, the surveyor observed the central bath door on 300 hall was unlocked. A clear bottle of blue fluid labeled [named] disinfectant cleaner was observed sitting just inside the door resting on a bedside chair. The bottle says hazardous to humans and animals, avoid contact with eyes and clothes and includes an emergency toll free number to call. A blue plastic container on the bedside commode contained anti-perspirant and [named] hygiene and barrier foam. b. On 11/05/24 at 10:36 AM, a deep bathtub, moist floor, shower area with 2 [named] fragrance body spray, and shampoo were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items when contaminated; 1 of 1 ice machines was maintained in a clean and sanitary condition, and cold dairy products were maintained at 41 degrees Fahrenheit or below for one meal observed. The findings are: 1. On 11/06/24 at 10:12 AM, Dietary Aide (DA) #7 opened the refrigerator, removed a pan of cookies, and placed it on the counter. Then DA #7 removed gloves from the glove box and placed them on her hands. Using her gloved hands, which were now contaminated, DA #7 picked up each piece of cookie from the pan placed them individually into separate bags to be served to the residents for lunch meal 2. On 11/06/24 at 10:22 AM, the following leftover dairy products were in a cooler by the steam table: a. There were 5 cartons of leftover whole milk, 2 cartons of chocolate ice cream, 4 cartons of sherbets and one carton of vanilla ice cream. The Assistant Dietary Manager was asked if she could check the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #11) of 1 resident residing in the Memory Unit, related to identification of the medications the resident was receiving related to the Resident's medical needs. The findings are: 1. On 11/05/24 at 9:18 PM, a review of the Resident's Care Plan, Physician's Orders, and the Minimal Data Set (MDS) for Resident #111 identified Resident #111's Care Plan did not identify the following medications ordered for Resident #111: a. Risperidone oral tablet 0.25 milligram (MG), the resident was given 1 tablet by mouth two times a day for severe dementia with agitation. b. Trazodone oral tablet 150 MG, the resident was given 1 tablet by mouth at bedtime related to the resident's sleep disorder. c. Duloxetine oral capsule delayed release particles 60 MG resident was given 1 capsule by mouth two times a day related to major depressive disorder. d. Mirtazapine oral tablet 7.5 MG, resident was given 1 tablet by mouth at bedtime related to moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure proper hand hygiene was performed during peri care to reduce the risk of cross contamination, and the spread of infection for 1 sampled (Resident #55) resident reviewed for bowel and bladder. Findings include: Review of an in-service was provided titled Return Demonstration-Peri Care, revealing the dates of in-servicing of staff was done on 03/13/2024, 06/05/2024, and 07/01/2024, but no educational information was provided. A policy/procedure was provided titled Perineal/Catheter Care, revised 11/22/2016, revealing after perineal care gloves should be changed before placing a clean brief under resident and replacing the bedspread and giving resident the call light. On 11/04/2024 at 11:30 AM, during perineal care Certified Nursing Assistant (CNA) #2, and CNA #3 were observed cleaning Resident #55 of urine and stool without changing their gloves or washing hands prior to placing a clean brief and lift pad under the resident, pulling Resident #55's clothing up, and looking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure catheter output bags were concealed in a privacy bag to protect the resident's dignity for 2 (Resident's #39, and #62) of 3 sampled residents who had an indwelling catheter on 300 hall. The findings are: 1. On 12/18/23 at 10:02 AM, the Surveyor observed Resident #39 sitting up in chair with the output catheter bag one quarter full of yellow liquid, attached to a trash can, facing the door, visible from the doorway and to visitors. a. On 12/18/23 at 12:54 PM, the Surveyor observed Resident #39, sitting up in chair with the output catheter bag 1/4 full of yellow liquid, hanging on a trash can, facing the door, visible from doorway and to visitors. b. On 12 /19/23 at 08:22 AM, the Surveyor observed Resident #39 up in chair with the output catheter bag 1/8 full of amber colored liquid, attached to a trash can, facing the door, visible from doorway entrance for visitors to see. c. Resident #39's physician order documented .APRN to change Super Pubic Foley 16fr(French)/5cc(cubic centimeters)- Change every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a resident's care plan was individualized to address the residents hearing loss to ensure appropriate care was received for one Resident (#41) of one sampled resident with hearing loss. The findings are: 1. Resident #41 had a diagnosis of dementia, no diagnosis of hearing loss. The minimum data set [MDS] with an assessment reference dated [ARD] of 12/10/2023 documented a brief interview of mental status [BIMS] of 08 which indicates a moderately impaired cognitive status. The MDS also documented highly impaired hearing, able to understand others. a. On 12/18/23 at 11:05 AM, during interview with Resident #41 the Resident was unable to hear what was being said. Resident #41 kept repeating stating what. Resident #41's relative stated, Yeah, she is hard of hearing. My uncle bought her some hearing aids a before, but she refused to use them. I think she may be a little [NAME]. b. Review of diagnosis list, physician orders, and care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident's individualized care plan were updated to ensure appropriate care was received for two Residents (R #33 and R#99) of 2 sampled residents. This failed practice had the potential to affect all 119 residents who reside in the facility. The findings are: 1. Resident #33 had a diagnosis of Alzheimer. The Annual Minimum Data Set [MDS] with an assessment reference date [ARD] of [DATE], had a brief interview of mental status [BIMS] of 5 (0-7 indicates severely impaired) and documented that R #33 required extensive assistance of staff with activities of daily living and fed self after set up. a. On 12/18/23 at 11:50 AM Resident #33 was observed sitting in a positioning chair at a table in the dining area, which is used for residents who need assistance, leaning to the left without any positioning devices in place. b. The care plan with a revision date of 05/04/2020 documented that resident was able to turn and position self, dress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a physician's order was in the electronic health record prior to administration of oxygen for 1 Resident (d#44) of 5 sampled residents; the facility failed to ensure oxygen tubing and nebulizer mouthpieces were stored in a sanitary manner to prevent the spread of bacteria for 2 Residents (#44 and #270) of 8 sampled residents. The findings are: 1.a. On 12/18/2023 at 11:43 AM, Resident# 44 was lying in bed wearing a nasal cannula attached to an oxygen concentrator that was providing oxygen at 2.5 Liters per minute. b. On 12/18/2023 at 2:15 PM, Resident# 44 was lying in bed wearing a nasal cannula attached to an oxygen concentrator that was providing oxygen at 2.5 Liters per minute. c. On 12/20/2023 at 9:42 AM, Resident# 44 was lying in bed wearing a nasal cannula attached to an oxygen concentrator that was providing oxygen at 2.0 Liters per minute. 2.a. On 12/18/23 at 11:01 AM, Resident #270 was sitting up in wheelchair with the nasal cannula tubing rolled up and hanging on the wheelchair handle connected…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure medications were not left in a resident's room for one Resident (R#97) of one sampled resident. The findings are: 1. Resident #97 had a diagnosis of dementia. The Quarterly Minimum Data Set [MDS] with an assessment reference date [ARD] of 12/05/2023 documented a brief interview of mental status [BIMS] of 14 which indicates cognitively intact. a. On 12/18/23 at 10:39 AM, R #97 was observed lying in bed watching tv, on top of an overbed table to the right of Resident's bed there was a medication containing 7 calcium carbonate chewable tablets. Another medication cup was sitting at beside on the table with a thick white substance in it. When questioned about the medication cups, R #97 said it was her pain cream, she uses it for the arthritis in her hands. b. Review of R #97's Physician's orders did not document an order for calcium carbonate and documented an order for Voltaren 1% topical gel every 6 hours as needed. c. On 12/20/2023 Licensed Practical nurse [LPN] #2 was asked, Should medications be left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with updating care plans and initiating a care area on the care plan. These failed practices had the potential to affect all 119 residents. The findings are: 1. A Recertification Survey was conducted on 09/28/2022 at the facility. During this survey, the team identified concerns with development and implementation of care plans and care plan revision. 2. There was no Plan of Correction noted from the previous survey. 3. A Recertification Survey was conducted on 12/18/23 at the facility. During this survey, the team identified concerns with care plans not having implementation of care areas and no revision. 4. A policy titled, Quality Assessment and Assurance (QAA) Quality Assurance and Performance Improvement (QAPI), provided by the Administrator on 12/21/2023 at 12:10 PM documented, .1. The facility will develop, implement, monitor, evaluate, and maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store the ice scoop in a closed container to ensure the infection prevention and control program was followed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infection. The findings are: 1. On 12/18/2023 at 10:11 AM, in 100 hall hydration room the ice chest containing ice for residents' water pitchers contained the handheld ice scoop laying directly on top of the ice. 2. On 12/18/2023 at 10:12 AM, the Surveyor asked Certified Nursing Assistant (CNA) #4 is the ice scoop supposed to be inside the ice chest? CNA #4 confirmed It is supposed to be in the side container. The Surveyor asked CNA #4 what is the reason for the ice scoop to be in the side container? CNA #4 confirmed to keep it clean. 3. On 12/18/2023 at 10:14 AM, the Surveyor asked Licensed Practical Nurse (LPN) #2 where is the ice scoop to be kept? LPN #2 confirmed in the container on the side of ice chest. The Surveyor asked LPN #2 what is the reason for the ice scoop to be in the side container?…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) after a decline in two or more Activities of daily living (ADL) for 1 (Resident #53) of 1 sampled resident whose MDSs were reviewed. This failed practice had the potential to affect all 119 residents in the facility. Findings are: 1. Resident #53 had a decline in 3 areas of ADLs according to the last 2 Quarterlies dated 6/6/23-and 9/1/23. a. The Minimum Data Set (MDS) a Quarterly Assessment with an Assessment Reference Date (ARD) of 6/6/23 documented that the resident required, bed mobility ext. assist of 1 person, eating supervision with set up, transfers ext. assist of 1 person, toileting ext. assist of 1 person. b. The Minimum Data Set a Quarterly Assessment with an Assessment Reference Date of 9/1/23 documented, bed mobility ext. assist of 2 person, eating supervision with set up, transfers ext. assist of2-personn, toileting ext. assist of 2 person. c. On 12/20/23 at 9:25AM, the Surveyor asked the MDS Coordinator (MDSC) to review the last 2 Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to complete a comprehensive assessment using the Resident Assessment Instrument (RAI) process within regulatory time frames for 2 (Resident #70, and #277) of 2 sampled residents whose MDS were reviewed. The findings are: 1. On 12/19/23 at 11:31 AM the Electronic Record was reviewed for resident #70. The admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 08/04/23 was completed. There were no other MDSs indicating no MDS for 120 days. 2. On 12/19/23 at 11:46 AM the Electronic Record (Electronic Record) was reviewed for Resident #277. The MDS Quarterly with An ARD of 8/7/23 was completed. There were no other MDSs. 3. On 12/20/23 at 9:25 AM, the Surveyor asked the MDS Coordinator (MDSC), how often is a MDS required? The MDSC stated, Every 3 months. The MDSC looked in the ER and stated Resident # 70 and #277 both should have had a quarterly done last month. That's my mistake. 4. On 12/20/23 at 9:35AM, the Surveyor asked the Director of Nurses how often regulatory MDSs are required. The DON stated, I'm not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.