Belaire Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and resident and staff interviews, the facility failed to provide incontinence care when a resident requested (Resident #44). The facility also failed to provide a privacy cover for urinary drainage bag which allowed the urinary drainage bag contents to be visible (Resident #31). This deficient practice was for 2 of 6 residents reviewed for dignity (Residents #44 and Resident #31).1. Resident #44 was admitted on [DATE] with diagnoses which included cerebrovascular accident (stroke), hypertension (high blood pressure), unspecified mood disorder, recurrent major depressive disorder. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #44 was cognitively intact, received a diuretic (a drug that causes the kidneys to make more urine) daily, was always incontinent of bowel and bladder, and required maximal assistance with incontinence care and toileting. A review of Resident #44's skin assessment dated [DATE] revealed redness to bilateral buttocks. An interview…

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 reviews, and Hospital Case Manager, Emergency Medical Services (EMS) Transporter, and staff interviews, the facility failed to allow a resident to return to the first available bed at the facility after being sent to the hospital for a medical and psychiatric evaluation. The resident remained in the hospital for over two weeks despite being cleared to return to the nursing home on the same day. This deficient practice was evidenced for 1 of 3 residents reviewed for transfer and discharge (Resident #92).Findings included: Resident #92 was admitted to the facility on [DATE] and discharged on 4/09/25 with diagnoses including intellectual disability, muscle weakness, and spinal cord disease. Review of 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #92 was severely cognitively impaired with wandering, verbal, and physical behaviors towards others. Review of nursing progress note written by Nurse #3 dated 4/09/25 revealed Resident #92 was combative with nursing staff. One-to-one…

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 ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents with new mental health diagnoses for 2 of 3 residents (Resident #37 and #6) reviewed for PASRR. The findings include: 1. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE]. PASRR level I was completed on 5/13/17 prior to admission with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition. The electronic medical record revealed Resident #37 was diagnosed with delusional disorder on 7/11/17, impulsive disorder on 3/30/18, mood affective disorder on 3/30/18, and attention-deficit hyperactivity disorder on 7/05/18. No PASRR level II was completed. An interview on 7/30/25 at 1:20 PM with Social Worker (SW) revealed she was responsible for completing PASRR…

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 observations, record review, and staff interviews, the facility failed to post cautionary signage outside of resident room that indicated the use of oxygen for 1 of 8 residents reviewed for respiratory care (Resident #95).Findings included: Resident #95 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia (low oxygen levels). A review of Resident #95's care plan created on 07/21/25 revealed a plan for oxygen therapy to relieve hypoxia due to COPD. The stated goal was that Resident #95 would be free from respiratory complications. Interventions included oxygen via nasal cannula as ordered, monitor for signs of respiratory distress and notify provider if indicated, and administer medications as ordered. Resident #95's physician orders revealed an order dated 07/22/25 for oxygen via nasal cannula as needed for shortness of breath at 2 liters per minute.Resident #95's admission Minimum Data Set (MDS) dated [DATE]…

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, Resident Representative, and Home Health Nurse interviews, the facility failed to include discharge instructions for a daily surgical wound dressing change for 1 of 3 sampled residents with wound care (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] and was discharged home on 5/18/25. Review of Resident #1's consultation records revealed an orthopedic consultation dated 5/16/25 with an order for daily dry dressing change to right hip. Resident #1's discharge Minimum Data Set assessment dated [DATE] revealed she was independent for decision making. Review of Resident #1's facility discharge instructions dated 5/18/25 for home care revealed no daily surgical wound dressing instructions. An interview on 6/24/25 at 9:56 AM with Resident #1's Representative revealed Resident #1 did not receive surgical wound care instructions when the resident was discharged from the facility on 05/18/25 until seen by Home Health on 05/21/25. An interview 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 record review, and staff, and orthopedic office Practice Manager interviews, the facility failed to provide care for a surgical wound as ordered by the consultant orthopedic physician for a daily surgical dressing for 1 of 3 sampled residents with wound care (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Hospital Discharge summary dated [DATE] revealed Resident #1 had diagnoses which included closed fracture of neck of right femur with routine healing. No surgical wound care instructions were noted on the hospital discharge summary. Review of facility orders revealed Resident #1 had a physician's order dated 5/08/25 to monitor the surgical dressing to right hip every shift and report any signs or symptoms of infection to physician every day and night shift for surgical wound care. Review of Resident #1's consultation records revealed an orthopedic consultation dated 5/16/25 with an order for daily dry dressing change to right hip. Review of facility orders revealed…

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 reviews and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) application was completed for a resident admitted with mental health diagnoses for 2 of 2 residents (Resident #12 and #55) reviewed for PASRR. The findings included: 1. Resident #12 was admitted to the facility on [DATE] with a diagnosis that included, in part, schizoaffective disorder. Review of Resident #12's medical record revealed the resident had a PASRR level I completed prior to her admission to the facility. The resident had a history of schizoaffective disorder and major depressive disorder as part of her admission. No PASRR level II had been completed per review of Resident #12's medical record. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was severely cognitively impaired, and she had no mood or behaviors. The MDS was not coded for a level II PASRR. Resident #12's care plan dated 10/05/2023 revealed she was care planned for psychotropic medications,…

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, observations and staff interviews, the facility failed to accurately enter the code status as full code in the Care Plan for 1 of 3 sampled residents (Resident #35) and the facility failed to revise the Care Plan for 1 of 1 sampled resident to include fluid restrictions and non-compliance with fluid restrictions (Resident #64). The findings included: 1. Resident# 35 was admitted to the facility on [DATE]. A physician's order dated 7/5/22 indicated Resident # 35 was a full code. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident# 35 had severely impaired cognition. A signed MOST form revealed Resident #35 had a full code status. A Care Plan dated 11/17/22 indicated Resident #35 had a code status of Do Not Resuscitate. A Care Plan dated 8/19/22 indicated Resident #35 had a code status of Do Not Resuscitate. An interview with the MDS Coordinator on 1/4/23 at 4:20 PM revealed she was responsible for entering the code status into the Care Plan. During the interview, she…

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 staff interviews, the facility failed to provide correct portions of pureed foods per the menu for 2 of 3 residents with a diet order for pureed foods (Resident #42 and #27). This failure had the potential to affect residents receiving pureed food. The findings included: A continuous observation of the lunch meal tray line occurred on 1/5/23 from 11:38 AM to 12:28 PM. On 1/5/23 at 12:23 PM, a 2-ounce serving utensil was observed used to plate pureed ham for Resident #42 and pureed beef for Resident #27. The plates for these residents were placed on the cart for delivery. Review of the lunch menu with the Dietary Manager (DM) revealed Residents with a diet order for pureed foods should receive a 4-ounce portion of pureed ham and a 5.33-ounce portion of pureed beef. During an interview on 1/5/23 at 12:25 PM, Dietary Aide #1 stated that the DM placed the serving utensils on the tray line, and she just picked up the utensils to plate the pureed foods for Residents #42 and #27. The DM stated in interview on 1/5/23 at 12:23 PM that she put 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with resident and staff, the facility failed to maintain wheelchair armrests in good repair for 2 of 5 residents reviewed for mobility device (Resident #177 and #180). The findings included: 1.a. Resident #177 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] assessed Resident #177 with severe impairment in cognition and her primary mobility device was a wheelchair. During an observation conducted on 01/03/23 at 11:15 AM, the right armrest of Resident #177's wheelchair was in disrepair with multiple torn spots and ripped lines. During the interview, Resident #177 was unable to tell the surveyor whether the broken armrest had caused any skin irritation to her right arm. On 01/04/23 at 12:39 PM, Resident #177 was seen sitting in her wheelchair in dining room and the right armrest remained in disrepair. She was wearing short sleeves and her right arm was seen in contact with the armrest during the observation. b.…

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, record review, and staff interviews the facility failed to remove 1 blister card of discontinued and expired promethazine, medication used for nausea and vomiting, for 1 of 5 medication carts (North medication cart #1) and 1 bottle of expired cranberry juice extract from 1 of 2 medication storage rooms (North medication storage room). The findings included: 1. a. Review of the facility's policy and procedures revised in August 2020 for discontinued medication under Section 5.3 indicated discontinued medications must be marked as discontinued and stored in a secure and separate area from the active medication until they were destroyed per facility policy or returned to the pharmacy when permissible by state regulation. Review of facility's policy and procedures revised in August 2020 for medication storage under Section 4.1 revealed all expired medications must be removed from the active supply immediately and destroyed in accordance with facility policy, regardless of amount remaining. During a medication storage check conducted on 01/04/23 at 2:20 PM, 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 observations, staff interviews and record review, the facility failed to provide 2 of 2 sampled residents with double portions per their preference (Residents #1 and #7). The findings included: 1. Resident #1 was re-admitted to the facility on [DATE]. Diagnoses included low body mass index (BMI), vitamin D deficiency, and dysphagia. A physician (MD) order dated 8/29/22 recorded a diet order for regular minced and moist diet, for dysphagia. A significant change Minimum Data Set assessment dated [DATE], assessed Resident #1 with unclear speech, usually understood by others, sometimes understands, severely impaired cognition, and able to feed himself with set up assistance. A care plan revised 12/6/22 identified Resident #1 with low BMI, stable weights, received double portions and fed himself with adaptive equipment. Interventions included to provide and serve a diet per order and preferences. A Nutrition assessment dated [DATE] written by the Registered Dietitian (RD) recorded Resident #1 received 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.