Rehabilitation Center of Belmond

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interviews, the facility failed to ensure 1 of 1 resident (Resident #7) reviewed for pressure ulcers received the necessary care and services to promote the healing of an existing pressure ulcer and prevent the development of new ulcers. Specifically, the facility failed to clean and apply medication to Resident #7's wounds on four separate shifts, failed to document weekly pressure ulcer measurements including depth, and failed to identify the wounds as pressure ulcers on the appropriate clinical record. The facility reported a census of 42 residents.Findings include:The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: NOTE:Regardless of the staging system or wound definitions used by the facility, the facility isresponsible for completing the MDS utilizing the staging guidelines found in the RAI (Resident Assessment Instrument) Manual.Stage 1 Pressure Injury (PI): Non blanchable erythema of intact skin Intact skin with a localized area…

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 review of the nursing schedules and staff interviews, the facility failed to provide a Registered Nurse (RN) in the facility for eight (8) hours per day on 4/5/26 and 4/12/26. The facility reported a census of 42 residents. Findings include:Review of the facility's nursing schedules for April 2026 lacked 8 hours of RN coverage on 4/5/26 and 4/12/26. In E-mail communication dated 4/21/26 at 12:49 PM, the facility Administrator reported the facility didn't have 8 consecutive hours of RN coverage on 4/5/26 and 4/12/26. In E-mail communication dated 4/22/26 at 1:08 PM, the Nurse Consultant explained the facility didn't have a policy for RN coverage as they just follow the regulation. During an interview on 4/22/26 at 2:15 PM the Administrator acknowledged the facility didn't have 8 hours of continuous RN coverage on 4/5/26 and 4/12/26. The Administrator added they had a plan in place moving forward for coverage.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinic record review, staff interviews, and policy review, the facility failed to administer medications per physician orders for 2 out of 2 residents reviewed (Resident #10 and #133) for significant medication errors. Resident #10 didn't receive his insulin medications the morning of 12/15/24. In addition, Resident #10 received short acting insulin with a blood sugar (BS) below 200 mg/dl (milligrams per deciliter) when the physician order directed staff to hold the insulin with a BS below 200 mg/dl. In addition, a nurse gave Resident #133 (a noninsulin treated diabetic) insulin instead of Resident #10 using Resident #10's insulin pen. The facility reported a census of 30 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 5, indicating severe cognitive impairment. The MDS listed Resident #10 as independent with bed mobility and transfers. Resident #10 used a walker for ambulation. The MDS included…

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 clinical record review, observations, staff interviews, and policy review the facility failed to assure a resident with a pressure ulcer received treatment and services, consistent with professional standards of practice, to promote healing of an unstageable pressure ulcer for 1 of 2 residents reviewed (Resident #24). The facility reported a census of 30 residents. Finding include: The Minimum Data Set (MDS) assessment identifies the following definition of pressure ulcers: Stage I is an intact skin with non blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible…

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, staff interview, and policy review the facility failed to assess, provide interventions, or notify the physician, the Registered Dietitian (RD), and the family about a resident with a significant weight loss (over 5% in month) for 1 of 2 residents (Resident #14) reviewed. In 1 months, timeframe, Resident #14 lost greater than 5% of their body weight (considered significant weight loss). The facility failed to notify the RD and physician for interventions to prevent further weight loss. The facility reported a census of 30 residents. Findings include: Resident #14's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS included diagnoses of cancer and heart disease. On 4/14/25 at 12:04 PM, observed Resident #14 in the dining room eating lunch. Resident #14's Weight Summary reviewed 4/15/25 identified the following weights: a. 3/9/25: 205.3 pounds (lbs.) b. 4/6/25:…

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 interview the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice by not changing oxygen (O2) tubing for 1 of 1 resident (Resident #8) reviewed. Facility reported a census of 30 residents. Findings include: A Minimum Data Set (MDS) dated [DATE]for Resident #8, included diagnoses of obstructive sleep apnea (frequent episodes of obstructed breathing while sleeping) and heart failure and received O2. A Brief Interview for Mental Status (BIMS) score of 15 indicated no cognitive impairment. Therapy. Observation on 4/15/25 at 9:50AM, in Resident #8's room was an O2 concentrator (machine that supplies O2) with tubing attached to a bipap machine (medical device that provides airway pressure to assist with maintaining breathing). The tubing supplying O2 from the concentrator to the bipap machine was not dated. Interview on 4/15/25 at 3:38 PM, Resident #8 stated she uses her bipap…

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 clinical record review, staff interviews, CDC (Centers for Disease Control and Prevention) recommendations and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed (Residents #10 and #133). After Resident #133 received Resident #10's insulin via an insulin pen, the facility failed to discard the insulin pens after the cross contamination occurred. The nurse put the insulin pens back into the medication cart after the medication error occurred and the nursing staff continued to use the insulin pens when administering Resident #10's insulin. The facility reported a census of 30 residents. Citation considered past noncompliance as the facility completed the following interventions prior to surveyor entering the building on 4/14/25: a. Staff B, LPN (Licensed Practical Nurse), received verbal education on 1/3/25. b. The facility provided the nurses education on…

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 clinical record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed with a new mental health diagnosis and start of new psychotropic medications (Resident #15). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 9 indicating moderately impaired cognition. The MDS revealed Resident #15 had diagnoses of psychotic disorder, adjustment disorder with depressed mood and visual hallucinations. The Care Plan for Resident #15 with a target date of 7/11/24 included a focus area for mood/behavior revealed exhibited visual hallucinations. The Care Plan further documented Resident #15 received psychotropic medications for the hallucinations and depression. The Clinical record revealed Resident #15 had the following diagnoses with effective dates: 1. Adjustment disorder 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to follow a physician's order for 1 of 1 residents reviewed receiving diabetic medication (Resident #14). The facility reported a census of 30 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] documented Resident #14 had a Brief Interview for Mental Status (BIMS) of 4, indicating severe cognitive impairment. The MDS further documented the resident had diagnoses to include medically complex conditions, renal insufficiency, and diabetes mellitus (DM). The Care Plan for Resident #14, with a target date of 6/25/24, documented under the focus section the resident had diabetes mellitus, with interventions to take routine insulin and a weekly injection to help control blood sugars. Review of records for Resident #14 revealed a Progress Note entry on 2/9/24 at 10:26 AM titled Physician Visit note, documented new orders received and noted from physician visit note to increase resident's Ozempic (Diabetic medication) to 1mg…

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 resident interviews, staff interviews, and facility records review the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility (Residents #4 and #19). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #4 dated 4/3/24 assessment identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Census tab in the clinical record revealed Resident #4 resided in room [ROOM NUMBER]. On 4/23/23 at 10:30 AM, the Administrator provided Resident #4's call light report from 3/23/24 to 4/23/24. The Administrator verified the column on the report titled In Room Elapsed Time was the duration the call light was on. On 4/23/24 at 1:05 PM, Resident #4 reported her call light can be long at times on all shifts. She stated she tried to be patient with the staff as she knew they were working with other residents. She stated she used the clock on the wall to time the call lights. In 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.

Based on observation, staff interviews and policy review, the facility failed to prepare food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 30 residents. Findings include: During an observation on 4/24/24 at 10:50 AM, Staff A, Cook, began the puree process for residents on a pureed diet. Wearing gloves, Staff A tore chicken off the bone and placed on a scale, took the gloves off, did not wash hands, and poured the chicken into the robot coupe (machine used to puree food) container. Using bare hands, Staff A touched the handle on a gallon of milk, the lid on the container, the button on the robot coupe, a drawer handle to get a spatula, a spatula, the robot coupe container, a box of tin foil, a marker from her pocket, and the warming oven. Staff A also touched the table top surface. Without washing or sanitizing hands, Staff A obtained a new container and touched tongs and a spatula to place the second food item to be pureed into the robot coupe container, placing the container onto the robot coupe…

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.