Belleair Health Care Center

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for one resident (#93) of two residents sampled for nutrition.Findings include: On 08/12/25 at 2:25 PM an observation was made of Resident #93. The resident was observed with a pink NPO (nothing by mouth) wrist band to right wrist and was noted to be drinking from a cup at the bedside. Resident #93 said family had provided the cup, and he was aware he was not supposed to be drinking from it, but he was thirsty.Review of Resident #93's medical record revealed a physician's order dated 07/27/25 and no end date for NPO diet, NPO texture, NPO consistency.Review of Resident #93's care plan with a revision date of 07/15/25 revealed [Resident #93] has a swallowing problem r/t [related to] oral cancer, and dysphagia [difficulty swallowing]. The goal revealed [Resident #93] will not have injury related to aspiration through the review date. The interventions revealed, Diet to be followed as prescribed. Encourage resident to eat in an upright position,…

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 observations, interviews, and record review the facility failed to provide appropriate wound care by not following professional standards of care for one resident (#87) of three residents sampled for non-pressure related skin conditions.Findings included: On 08/12/25 at 1:45 PM an interview was conducted with Resident #87, who said he was here at the facility due to a wound on the right foot that became infected prior to admission to the facility. Observation of the resident's right foot revealed the right foot was covered in a gauze dressing and dated 08/12/25. Resident #87 said the dressing had been changed earlier today.An observation was conducted on 08/13/25 at 12:00 PM of Resident #87's right foot covered in a gauze dressing dated 08/13/25. Review of Resident #87's electronic medical record revealed a wound care physician order dated 07/29/25 for wound care-right hallux/plantar-apply collagen then apply calcium alginate-wrap with (gauze) and then (self-adherent bandage) daily and as needed. The physician order for the right heel dated 07/30/25 revealed wound…

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 splints were applied according to physician orders for one resident (#14) out of one resident reviewed for splints.Findings included: An observation was conducted on 08/12/2025 at 1:52 PM. Resident #14 was lying in bed asleep with covers up to neck with both hands exposed. Resident #14 was observed to have a right-hand contracture with no splint in place. An observation was conducted on 08/14/2025 at 9:43 AM. Resident #14 was in bed watching television. The right hand was contracted with no splint or washcloth in place. Review of Resident #14's physician orders revealed an order dated 08/13/25 Restorative Nursing for splinting. Pt [patient] to tolerate R [right] palm guard with finger separators and rolled towel placed in elbow crease on 24 hours with removal for skin checks and hygiene.Review of Resident #14's Therapy Comprehensive Screen with an effective date of 8/11/25 revealed Resident #14 had current orders for adaptive equipment/device/splint/brace. The type of adaptive equipment…

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 observations and interviews the facility failed to provide proper storage of medications for two residents (#93 and #11) of 38 sampled residents. Findings included: On 8/12/25 at 2:33 PM an observation was made of a bottle of “Dakin's Solution quarter strength” (a pharmacy grade bleach solution to treat wounds) was noted on Resident #93's dresser in his room. On 08/13/25 at 1:13 PM an observation was made of Resident's #93's dresser and revealed the bottle of “Dakin's Solution” was still present in the resident's room. On 08/13/25 at 1:14 PM an interview was conducted with Nurse F, a Licensed Practical Nurse who confirmed that the bottle of “Dakin's Solution” should not be kept on the resident's dresser in the room but should be stored on the treatment cart. Nurse F then removed the bottle from the resident's room. On 08/13/25 at 1:15 PM an interview was conducted with the Director of Nursing (DON). The DON said it was her expectation treatment supplies and medications were to be stored on the treatment cart and secured. 2. On 08/12/25 at 9:02 AM a container of Desitin…

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 observations, interviews, and record review the facility failed to maintain proper infection control practice during wound care for one resident (#87) of three residents sampled for non-pressure related skin conditions.Findings included:On 08/12/25 at 1:45 PM an interview was conducted with Resident #87, who said he was here at the facility due to a wound on the right foot that became infected prior to admission to the facility. Observation of the resident's right foot revealed the right foot was covered in a gauze dressing and dated 08/12/25. Resident #87 said the dressing had been changed earlier today.An observation was conducted on 08/13/25 at 12:00 PM of Resident #87's right foot covered in a gauze dressing dated 08/13/25. Review of Resident #87's electronic medical record revealed a physician order dated 07/29/25 for wound care-right hallux/plantar-apply collagen then apply calcium alginate-wrap with (gauze) and then (self-adherent bandage) daily and as needed. The physician order for the right heel dated 07/30/25 revealed wound care-right heel-cleanse with…

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, and interview, the facility failed to demonstrate an effective response to grievances pertaining to care and life in the facility voiced by Resident Council. In addition, four (#6, #7, #8, and #5) of eleven sampled residents reported call bell light untimeliness response by staff. Findings included: A review of Resident Council meeting minutes for 05/2024, 06/2024, 07/22024, 08/2024, and 09/2024 was conducted on 09/23/2024. Review of the meeting minutes dated 05/16/2024, reflected Old Business concerns showed two room numbers beds not being made, 11-7 talking loud in hallway, not getting ice water 3-11. Further review of the meeting minutes reflected no response from the facility pertaining to the concerns. Review of the meeting minutes dated 06/11/2024, reflected no documentation of Old Business concerns. New Business concerns for nursing were listed, 400 hall call lights 11-7. Review of the meeting minutes dated 07/02/2024, reflected an Old Business concern, call lights 11-7. The meeting notes documented New Business concerns: call light…

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, and interview, the facility failed to ensure a functioning grievance process for two (#3 and #5) of three sampled residents related to missing items. Findings included: 1. A review of Resident #3's clinical chart, the face sheet reflected an admission of 10/22/2023 and a subsequent discharge of 11/03/2023 to another skilled nursing facility. On 09/23/2024 at 1:43 p.m., Resident #3's family member was interviewed by phone. He stated he had filed the grievance in October 2023 about a missing hearing aid. He said he was told by the nurse to fill it out. They were supposed to set up an appointment with the audiologist and they never followed up. I called the administrator several times. I left e-mails. We wanted to see if the audiologist would come to her new facility for the appointment. Four months later, we had no results. They never followed up with an appointment. We tried the grievance process. It did not work for us. We ended up buying her a new pair after waiting so long, she could not hear without them. We would like to be reimbursed. A…

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 give the opportunity to choose activities of interest for one (Resident #322) of five residents sampled. Findings included: An observation was conducted on 10/4/2023 at 9:23 a.m. Resident #322 was heard from the hallway, crying loudly. Staff B, Licensed Practical Nurse (LPN) went into the resident's room and the Director of Nursing (DON) was observed to be standing outside of Resident #322's room. Staff B, LPN came out of the room and said to the DON, I think I have [Resident #322] calmed down. Resident #322 began to cry loudly again and Staff B, LPN said, Oh, I guess he's not calmed down. Resident #322 was observed to be on the phone crying saying, I need your help, I need you here. The DON instructed Staff B, LPN to get a psychiatric consult. An interview was conducted with Staff B, LPN on 10/4/2023 at 10:04 a.m. Staff B, LPN stated, we are getting him a psych consult, but I would hate to give him Ativan as Resident #322 has never acted…

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 record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for two (Residents #77, #32) of three residents sampled for PASARR Level II. Findings included: A review of Resident #77's admission record showed the resident was initially admitted to the facility on [DATE]. He was readmitted back to the facility on [DATE] with diagnoses of traumatic brain injury, schizoaffective disorder bipolar type, anxiety disorder, and major depression disorder. A review of Resident #77's Preadmission Screening and Resident Review (PASARR) dated 10/26/20 showed qualifying mental health diagnoses of anxiety disorder, bipolar disorder, and depressive disorder and no PASARR Level II was required. A review of the admission Minimum Data Set (MDS), Section I, Active Diagnoses, with an Assessment Reference Date (ARD) of 9/28/2020, quarterly MDS with ARD of 7/30/23, 1/29/23, 7/31/22, and annual MDS with an ARD…

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 one (Resident #34) of thirty-eight sampled residents, who were reviewed for care planning, was care planned with problem areas, goals, and interventions. Findings included: On 10/2/2023 and 10/3/2023 during the 7:00 a.m.-3:00 p.m. shift, Resident #34 was visited several times while in her room. She was observed initially lying in bed and with her legs propped up on a pillow and positioned very close to the edge of the bed. Resident #34 was not presenting with any behaviors, pain or discomfort during each time visited. However, Resident #34's bilateral upper extremities appeared to be somewhat contracted, and/or with movement impairment. She was not wearing braces or splints on her extremities. There were no braces or splints in the room. Resident #34 was interviewable. She was very pleasant and happy to be visited. The resident said she could not move her fingers and at times had pain. She said her fingers had been that way since…

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, review of temperature recording logs and review of policies and procedures, the facility failed to ensure that cold Time/Temperature Control for Safety (TCS) food was held at 41 degrees Fahrenheit (F) or below during the lunch meal service on 8/26/21. The affected food was intended to be served to 8 residents out of 104 residents who consumed the facility's prepared food. The findings included: On 08/26/21 at 12:06 PM, during the lunch meal service, there was a tray of approximately 17 individual butterscotch puddings held without ice or cooling device. The surveyor took the holding temperature of an individual butterscotch pudding from this tray, using the facility's thermocouple, and the temperature was 55 degrees F, rather than at 41 degrees F or below. Photographic evidence obtained. Butterscotch pudding is a TCS food. Interview with the Food Service Director (FSD) at that time revealed that the butterscotch pudding came from a can that was refrigerated overnight. During an interview on 08/26/21 at 12:07 PM with Dietary Aide, Staff H, she said…

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 observations, resident and staff interviews, and medical record review, the facility failed to ensure one of thirty-four sampled residents (#54) was assessed for a wound. Findings included: On 8/24/2021 at 10:00 a.m. and at 12:15 p.m., Resident #54 was observed in her room, seated in a wheelchair with an unraveled dressing on her right lower leg. Two ends of the dressing were touching the floor and appeared blood stained. On 8/24/2021 at 12:15 p.m., Resident #54 confirmed she had a wound on her leg and that it itched at times which was why the bandage had unraveled. Resident #54 also reported that she had another area on her right arm that burned and itched as well. She was wearing long sleeves and proceeded to push up her right sleeve past her elbow. Observation revealed the right inner bend of the arm had a raised area approximately the size of a nickel. The area was deep red in color and appeared to be scabbed on the left side of the wound. A large rectangular bandage was observed pulled off and barely sticking on the lower part of the resident's arm. It appeared as…

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 staff and resident interview, the facility failed to ensure that one of one (#319) sampled dialysis resident of two facility residents receiving dialysis received care consistent with professional standards of practice and the resident's plan of care. The facility failed to ensure communication with the dialysis facility in order to ensure antibiotics were provided in accordance with physician's orders for Resident #319. The findings included: Clinical record review for Resident # 319 revealed an admission record with an admission date of 08/16/21 with diagnoses to include: end-stage renal disease (ESRD), pneumonia, cellulitis unspecified, and acute osteomyelitis of the left ankle and foot. A review of the most recent minimum data set (MDS) assessment dated [DATE] documented a brief interview for mental status (BIMS) score of 12 indicating moderate cognitive impairment. Section N of the MDS documented that Resident # 319 received an antibiotic for five days since…

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 observations, staff and resident interviews, medical record review and policy review, the facility failed to ensure medications to include one tube of Anti-itch cream was properly stored and secured to ensure one (#54) of 34 sampled residents could not access it, during two (8/24/2021 and 8/25/2021) of four days observed. Findings included: On 8/24/2021 at 12:15 p.m., Resident #54 was observed in her room . She was noted with bandage dressing that was unraveled on her right lower leg. Upon interviewing Resident #54, she expressed that staff had put the dressing on and she does have itching in the area where the dressing was placed. During the interview, the surveyor observed a full 35 gram tube of Extra Strength Anti-Itch Cream, Ban-Itch topical analgesic and skin protectant on the resident's wall dresser. Resident #54 was asked where the tube of itch cream came from and she said that they gave it to her and she uses it when she needs it. Resident #54 could not remember a specific person who gave her the tube of cream, but did reported that it was from a nurse. She said…

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.