Inspection Reports for
Belleview Care Center

The facility failed to maintain a system to assure that accurate quarterly accounting statements of resident trust fund accounts were sent to residents or their representatives, affecting four sampled residents. The Business Office Manager had not been sending these quarterly reports as required.

The complaint investigation found that Resident #1 pushed Resident #2 to the ground, constituting physical abuse. Resident #1 has a history of aggression and was experiencing a urinary tract infection at the time. Both residents were separated and sent for psychological evaluation. Staff were retrained on abuse prevention.

The facility failed to protect Resident #2 from physical abuse when Resident #1 pushed Resident #2 to the ground. The facility responded by separating the residents, conducting an investigation, retraining staff on abuse prevention, and updating care plans. Resident #2 had no injuries and the noncompliance was corrected promptly.

The complaint investigation found substantiated incidents where Resident #1 physically assaulted Residents #2, #3, and #4. The facility failed to immediately intervene despite 1:1 monitoring. Resident #1 was sent for psychiatric evaluation and discharged from the facility.

The facility failed to protect residents from abuse when Resident #1 punched and hit other residents multiple times. Staff did not immediately intervene despite 1:1 monitoring. Resident #1 was transferred to a psychiatric hospital and the facility implemented staff education on abuse prevention.

The facility failed to ensure food served was palatable and attractive for two of 18 sampled residents, and failed to assure two residents had access to a call light while lying in bed, potentially risking resident safety. Both deficiencies were noted with minimal harm or potential for actual harm.

The facility was found deficient in multiple areas including failure to maintain residents' rights and dignity during ADL care, inconsistent code status documentation, unsafe and unclean environment, medication administration errors, inadequate personal hygiene care, improper respiratory care, food service issues, unsafe kitchen practices, malfunctioning freezer, and inaccessible call lights for residents.

The complaint involved a resident (Resident #2) who reported being forcibly fed by a Certified Nurse Aide (CNA A) despite expressing refusal. The resident was emotionally upset and tearful. The facility did not report the abuse allegation to the State Agency within the required two-hour timeframe and failed to conduct a full investigation including obtaining staff statements. The Administrator considered the issue customer service rather than abuse and did not report it. The CNA was later severed from the work environment.

The facility failed to maintain a safe environment due to water leaks and mold in a resident room and adjacent utility room. Additionally, the facility failed to prevent a staff member from forcibly feeding a resident against their wishes and did not properly investigate or report the abuse allegation in a timely manner.

The facility failed to ensure staff notified the physician when Resident #4 refused to take prescribed tacrolimus medication, an antirejection drug, and also refused food and liquids, leading to a hospital transfer. Documentation and communication deficiencies were noted regarding the resident's condition and medication refusal.

The facility failed to maintain the ceilings in the memory care unit, with multiple holes observed in various locations. The Director of Maintenance and Administrator acknowledged the issues and stated that contractors would be returning to repair the ceilings, but no repair date was known.

The facility failed to ensure residents were treated with dignity, as evidenced by poor hygiene and lack of showers for several residents. Additionally, licensed nurse staff failed to carry out physician's medication orders properly, leaving blanks in medication and treatment administration records for multiple residents.

The complaint investigation found that the facility staff failed to administer the ordered Levemir insulin to Resident #3, did not notify the physician of the missed doses, and the resident was hospitalized with critically high blood glucose and complications including diabetic ketoacidosis and kidney failure.

The facility failed to administer Levemir insulin to Resident #3 on 11/28/23 and 11/29/23, leading to critically elevated blood glucose levels and hospitalization with diabetic ketoacidosis and kidney failure. Staff did not notify the physician or properly manage medication delivery and administration despite the medication being available in the emergency kit.

The facility failed to ensure nursing staff followed physician orders for treatment and oxygen therapy, provide adequate assistance with activities of daily living including bathing and incontinent care, maintain timely response to call lights, and provide sufficient staffing to meet resident needs. Several residents did not receive scheduled showers, experienced delayed call light responses, and one resident was left on a bedpan for an extended period.

The facility was found deficient in multiple areas including failure to answer call lights timely, inadequate monitoring of residents, failure to accommodate resident needs, lack of communication with resident council, financial management issues, inconsistent notification of resident rights, conflicting advance directive documentation, unsafe and unclean environment in memory care unit, incomplete care plans, medication administration errors, inadequate respiratory care, insufficient assistance with activities of daily living, inadequate staffing levels, and infection control lapses including improper linen handling and hand hygiene.

The facility failed to update and revise the care plans for four residents who used side rails or bolsters on their beds, despite assessments and observations indicating their use. The care plans did not reflect the current use of these devices, and staff interviews confirmed inconsistent care planning practices.

The complaint was substantiated. The resident's daughter reported multiple bounced reimbursement checks totaling $2,016.00 and additional banking fees of $30.00. The facility eventually paid the owed amount plus fees in cash after over three months.

The facility failed to refund resident funds within 30 days of discharge for one resident, resulting in multiple bounced reimbursement checks and delayed payment. The issue was eventually resolved with a cash payment to the resident's daughter after over three months.

The facility failed to complete criminal background checks for three CNAs prior to resident contact, did not develop appropriate discharge plans for two residents, had insufficient nursing staff leading to missed showers and restorative aide services, and failed to maintain hot water in two resident rooms affecting three residents.

The facility was found deficient in multiple areas including failure to complete timely criminal background checks for staff, failure to provide written transfer/discharge notices and bed-hold policy to residents and representatives, incomplete and outdated care plans, inadequate pressure ulcer care and documentation, inconsistent post-fall evaluations, failure to monitor weight loss adequately, failure to provide ordered respiratory care and maintain oxygen equipment properly, failure to maintain required RN coverage separate from the DON role, failure to assist a resident in obtaining dental care, and lapses in infection control practices including catheter bag placement, hand hygiene during peri-care, and COVID-19 screening of staff.