Heritage of Bel Air

S483.60(i) Food safety requirements. The facility must - S483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to serve food in a manner to prevent potential food borne illnesses. The facility failed to ensure bare hands were not used to touch ready-to-eat food items. This practice had the potential to affect all residents in the facility who ate meals from the kitchen. The facility staff identified a census of 98. Findings are:A. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 81-2,272.10*(Replaces 2013 Food Code 3-301.11 (B), (C), (D), and (E) Preventing Contamination from Hands). -Except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact 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.

S483.60(d) Food and drink Each resident receives and the facility provides- S483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; S483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.Licensure Reference Number 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to serve room trays at a palatable temperature. The sample size was 9 and the facility census was 98. Findings are: Review of the Nebraska Food Code effective 3/8/12 revealed the following:-refrigerated potentially hazardous food (time/temperature control for safety food) would be at a temperature of 41 degrees or below when received, and-potentially hazardous food that was cooked to a temperature and for a time specified and received hot would be at a temperature of 135 degrees or above. During an interview on 7/28/25 at 10:20 AM Resident 66 reported that they sometimes eat meals in their room and the food is cold most of the time. The following observations were made on 7/29/25:-at 12:04 PM the hot…

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.

S483.45(f) Medication Errors. The facility must ensure that its- S483.45(f)(1) Medication error rates are not 5 percent or greater;This REQUIREMENT is not met as evidenced by Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5 percent (%). Observations of 25 medications administered revealed 2 errors resulting in an error rate of 8%. The medication errors were related to 1 (Resident 6) of 5 residents sampled. The facility identified a census of 98.Findings are:A. Review of the facility policy Medication Errors with a revision date of 2/18 revealed the facility was to ensure residents were free of medication error rates of 5% or greater. A medication error was defined as the observed or identified preparation or administration medications which were not in accordance with the prescriber's order or the manufacturers specifications regarding the preparation and administration of the medication. B. Review of the Prefilled Insulin Pen Competency Form used by 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 LICENSURE REFERENCE NUMBER 175 NAC 12-006.18(B)Based on observation, interview, and record review; the facility failed to implement the required Personal Protective Equipment (PPE-items such as gowns and gloves that are worn to protect care givers during the provision of care and to protect other residents from being exposed to potential communicable disease) during the provision of care for Resident 35. The facility census was 98.Findings are: A. Review of the facility policy [NAME] Senior Living (VSL) Policy for Enhanced Barrier Precautions (EBP) dated 4/12/24 revealed the following:-EBP referred to an infection control intervention designed to reduce transmission of multidrug resistant organisms (germ that is resistant to medications) (MDRO) that required the use of gowns and glove use during high contact resident cares,-EBP would be initiated on residents with an infection with a targeted MDRO.-PPE for EBP is only necessary when performing high-contact care activities in resident room and spa-room.…

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.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i) Based on record review and interview; the facility failed to implement assessed fall interventions, and to revise and/or develop new interventions for the prevention of ongoing falls for Resident 12. The facility census was 101 and the sample size was 5. Findings are: A. Review of the facility Fall Prevention Management Standards with revision date of 1/2024 revealed all residents were to be reviewed during pre-admission/admission to determine their risk for falls. When a resident was identified at risk for falls, the resident's care plan was to be updated to reflect the potential safety hazard. Approaches/ interventions were to be implemented and maintained related to identified areas of risk. If a fall was to occur, staff were to investigate and collect factual evidence related to the fall. A Root Clause Analysis was to be completed to find out what happened and to determine what could be done to prevent it from happening again. B. Review of Resident 12's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool…

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.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility failed to have physician documented, resident specific clinical rationale for not attempting gradual dose reductions for Resident 7's psychoactive (medications that affect brain activity associated with mental processes and behavior) medication. The sample size was 5 and the facility census was 101. Findings are: Review of the facility management standard Psychoactive Medications and Medication Regimen Review dated 6/2024 revealed the following: -Each psychoactive medication had an appropriate diagnosis to support the use of the medication. -Gradual Dose Reductions were required for all psychoactive medications. -The interdisciplinary Team acted as the resident advocate to ensure psychoactive medications were necessary, to ensure quality of life for each resident. -The facility utilized appropriate resources to assist in managing psychoactive medications that were prescribed for residents, including the attending physician, the medical director as needed, the consulting pharmacist, 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 Licensure Reference Number 175 NAC 12-006.18 (B) Licensure Reference Number 175 NAC 12-006.18 (D) Based on observation, interview, and record review; the facility failed to implement Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multi-drug resistant organisms [MDRO's]) during wound care and perform hand hygiene at appropriate intervals during high contact care activities for Resident 30, and to correctly use Personal Protective Equipment (PPE) to prevent the potential spread of Covid-19 related to resident 37. The total sample size was 28. The facility census was 101. Findings are: A. Review of the facility policy Standard and Transmission Based Precautions (TBP), undated, revealed the following: -TBP would be implemented for residents known or suspected to be infected with an infectious agent requiring additional control measures, -hand hygiene would be performed after contact with blood, body fluids, contaminated items, and immediately after removal of…

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.

Licensure Reference Number 175 NAC 12-006.10 Based on record review and interview, the facility failed to administer insulin medication as ordered for 1 (Resident 21) of 39 sampled residents. The facility census was 101. Findings are: A. Review of Resident 21's undated care plan revealed the resident had a diagnosis of Diabetes and was at risk for abnormal blood sugar levels related to this. The care plan goal was to maintain blood sugars within normal range using the following interventions: 1) follow diet as ordered 2) discuss meal times, portion sizes, restrictions, snacks, and compliance with nutritional regimen as needed and 3) give medications as ordered. Review of Resident 21's Medication Administration Records dated April, May and June of 2023 revealed the following: -physician's order dated 11/29/2022 for Insulin (Novolog) injection solution, give 3 units subcutaneously (under the skin) two times a day for blood sugar levels over 200; -on 4/10/23 at 9:00 AM, blood sugar = 158 and resident was administered 3 units of Novolog insulin to the abdomen, left upper quadrant;…

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 Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure residents were free from unnecessary medications related to long term use of antibiotic medications for 2 residents (Resident 79 and 96) that did not specify a duration and had no supporting documentation for clinical use based on laboratory results. The sample size was 2 and the facility census was 101. Findings are: A. Review of the facility policy Antimicrobial Stewardship Program with a revised date 4/2023 revealed the following: -The overall goal of the Antibiotic Stewardship Program (ASP) is to prevent undesirable outcomes related to antibiotic misuse by optimizing the selection of drug, dose, route and duration of therapy. Antibiotic use protocols and systems to monitor antibiotic use will be implemented to achieve ASP goals. -The Antimicrobial Stewardship Committee has been established to provide support and oversee activities of the ASP. The committee and the ASP will be part of 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 Licensure Reference Number 175 NAC 12-006.17 Based on observations, interview and record review, the facility failed to implement infection control measures to prevent the potential spread of Covid-19 for 1 (Resident 62) of 6 sampled residents. The facility census was 101. Findings are: A. Review of the facility policy Covid-19 Guidelines dated 5/11/23 revealed the purpose of the policy was to provide clarification regarding Covid-19, to minimize exposure and promptly identify residents, team members and visitors with clinical features and risk for Covid-19. Transmission-Based Precautions should be implemented in the event of ongoing Covid-19 transmission within the facility that is not controlled with initial interventions. Residents that are identified at high risk are placed in a yellow zone related to transmission-based precautions and staff should wear an N95 mask and eye protection (face shield or goggles) when providing resident cares. B. An observation of 3 staff members entering room [ROOM NUMBER]…

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.