Inspection Reports for
Bellaire at Stone Port

The investigation supported the self-report of non-compliance related to medication administration errors. A violation was issued for failure to administer medications according to physician orders, specifically involving phenobarbital dosing errors for one resident.

The investigation supported the self-report of non-compliance related to medication administration errors. A violation was issued for failure to administer medications according to physician orders, specifically an incorrect dose of gabapentin given to a resident.

The inspection identified multiple violations including unsecured staff records, incomplete admission physical examination documentation, restricted resident freedom of movement due to locked doors in the memory care neighborhood, and failure to conduct fire drills on all shifts each quarter.

The investigation supported the self-report of non-compliance related to medication management, including failure to implement a written medication management plan and failure to administer medications according to physician orders. Violations were issued and corrective actions were planned.

The inspection found non-compliance with several standards including failure to annually update fall risk ratings, failure to post a written schedule of activities on the secured unit, failure to ensure annual review of residents' rights acknowledgements, and failure to include Do Not Resuscitate orders in Individualized Service Plans.

The investigation supported the self-report of non-compliance with regulations and violations were issued related to failure to comply with licensing regulations and failure to ensure resident health, safety, and well-being, including an incident where staff removed a resident's tooth improperly.

The evidence gathered supported some, but not all, of the allegations related to Resident Care and Related Services. The complaint was partially substantiated.

The investigation supported some, but not all, of the allegations. The facility was found non-compliant with standards related to Resident Care and Related Services, specifically failing to ensure residents did not receive medications or dietary supplements to which they have known allergies.

Complaint was determined valid based on record review and staff interview regarding delayed therapy evaluations for Resident A admitted on 11/21/2023.

The complaint was determined to be valid. The facility failed to ensure timely habilitative services for a resident admitted from a skilled nursing facility, with delays in Physical and Occupational Therapy evaluations until nearly a month after admission.

The complaint was not substantiated. The allegation of verbal abuse was found invalid based on the resident's interview. Allegations regarding chemical restraints and insufficient staff screening could not be substantiated due to lack of specific information.

The investigation found the allegation of verbal abuse invalid based on the resident's interview, and the allegations regarding chemical restraints and staff screening could not be substantiated due to lack of specific information. However, a violation unrelated to the complaint was identified regarding inconsistent documentation of staff responses to 'as needed' medication administration.

The inspection identified multiple violations including incomplete private duty personnel records, individualized service plans (ISPs) not reflecting all assessed resident needs, and one medication not administered as ordered. Corrective actions were required to address these deficiencies to maintain compliance.

Complaint was related to allegations of neglect and falsifying documentation but was determined to be not valid based on investigation findings.

The investigation did not support the allegation, determining the complaint to be not valid. One non-complaint-related violation was found regarding four of five individualized service plans not being signed by all involved parties.

Complaint related: Yes. The allegation of abuse was not substantiated, but the allegation of failure to document an incident was substantiated.

The allegation of abuse was determined to be not valid, but the allegation that an incident was not documented in the resident's record was found to be valid. A late entry was made to the resident's narrative charting to correct this.

The complaint was substantiated based on documentation and interviews confirming insufficient staffing on the secured unit night shifts between 2022-01-02 and 2022-01-13.

The investigation found that the facility failed to ensure three direct care staff were on duty at all times on the secured unit during the night shift, supporting the complaint as valid.

The facility failed to ensure the safety and well-being of a resident during care on 2021-11-28, where a direct care aide was witnessed hitting a resident after the resident became physically aggressive. The resident had slight puffiness on the upper lip but no other injuries or complaints of pain.

The inspection found multiple violations including failure to list all assessed needs on individualized service plans, failure to implement current medication management plans, failure to ensure medication administration according to physician orders, failure to indicate residents' inability to use emergency call systems on service plans, failure to conduct fire drills on each shift for each quarter, and failure to complete criminal record checks within 30 days of hire for staff.