Inspection Reports for Belmont Healthcare Center
506 RIVERVIEW ROAD, WV, 26134
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 20, 2024
Visit Reason
The inspection was conducted as an investigation survey concluding on 10/23/24, triggered by a complaint or allegation.
Findings
Belmont Healthcare Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The facility was found to be in substantial compliance with previously cited deficient practices based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
Investigation survey concluding on 10/23/24; facility found in substantial compliance with previously cited deficient practices.
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 5
Oct 23, 2024
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Belmont Healthcare Center from 10/21/24 to 10/23/24 to assess compliance with regulatory standards.
Findings
The facility was found deficient in multiple areas including incomplete neurological assessments after resident falls, inaccessible resident call lights, improper documentation of resident capacity and neurochecks, storage of dented food cans, and failures in infection prevention and control practices including improper catheter care and unsanitary laundry room conditions.
Severity Breakdown
SS=E: 3
SS=D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to complete neurological assessments following resident falls for Resident #13. | SS=E |
| Residents #46 and #38 had call lights that were not accessible, violating resident call system requirements. | SS=D |
| Incorrect documentation and maintenance of capacity forms and neurochecks for Residents #23 and #13. | SS=D |
| Storage and use of dented food cans in the kitchen. | SS=E |
| Failure to maintain effective infection control practices in the laundry room and during catheter care for Resident #44. | SS=E |
Report Facts
Facility census: 60
Residents reviewed: 25
Dented cans found: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #51 | Licensed Practical Nurse | Confirmed call light was out of reach for Resident #46 |
| LPN #9 | Licensed Practical Nurse | Confirmed Resident #38 was unable to reach call light and expressed shock at NA #53's failure to follow infection control protocols |
| NA #53 | Nurse Aide | Performed catheter care on Resident #44 without proper infection control practices |
| Culinary Aide #38 | Dietary Staff | Acknowledged dented cans in kitchen should have been removed |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 2
Oct 22, 2024
Visit Reason
The inspection was an annual recertification survey conducted to assess compliance with federal and state regulations.
Findings
The facility was found deficient in maintaining the sprinkler system according to NFPA 25 standards and in ensuring fire and smoke barriers were properly constructed and maintained per NFPA 101. These deficiencies could affect all residents, staff, and visitors.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain sprinkler system in accordance with NFPA 25, including presence of a standard response sprinkler head in an attic compartment with quick response heads. | SS=F |
| Failure to ensure fire and smoke barriers were constructed and maintained according to NFPA 101, including unsealed penetrations in the attic smoke barrier above Resident Room 402. | SS=F |
Report Facts
Census: 61
Sample size: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Named in relation to corrective actions for sprinkler system and fire barrier deficiencies | |
| Facility Maintenance Director | Interviewed and acknowledged findings related to sprinkler system and fire barrier deficiencies |
Inspection Report
Annual Inspection
Census: 616
Deficiencies: 1
Oct 22, 2024
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements.
Findings
The facility was found to be in compliance with federal and state requirements, including the Facility Emergency Preparedness Plan. Previous deficiencies cited were corrected by the time of the re-visit.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and rules in a language they understand as required by 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Report Facts
Sample size: 80
Census: 616
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Sep 24, 2024
Visit Reason
An unannounced facility reported incident/complaint investigation survey was conducted at Belmont Healthcare Center from 09/23/24 to 09/24/24.
Findings
The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Five facility reported incidents were investigated and all were found to be unsubstantiated.
Complaint Details
Facility Reported Incident (FRI) #31319, #31858, #32165, #32333, and #32525 were all unsubstantiated.
Report Facts
Facility Reported Incidents investigated: 5
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Jul 2, 2024
Visit Reason
An unannounced complaint investigation survey was conducted at Belmont Healthcare Center from 07/01/24 to 07/02/24.
Findings
The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rule. Complaints #33038 and #32909 were unsubstantiated with no related or unrelated deficiencies cited.
Complaint Details
Complaints #33038 and #32909 were unsubstantiated with no related or unrelated deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 0
Jul 2, 2024
Visit Reason
An unannounced revisit was conducted at Belmont Healthcare Center from 07/01/24 to 07/02/24 for the complaint survey concluding on 05/21/24.
Findings
The citations from the previous complaint survey were found to have been corrected and are reflected on the CMS-2567B.
Complaint Details
This visit was a follow-up to a complaint survey concluding on 05/21/24; the deficiencies cited were corrected.
Report Facts
Census: 58
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 9
May 21, 2024
Visit Reason
An unannounced complaint survey was conducted based on multiple complaints substantiated involving abuse, neglect, and care deficiencies at Belmont Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to revise care plans timely, failure to prevent resident-to-resident abuse, failure to provide accurate and complete investigations, failure to maintain accurate medical records, failure to ensure respiratory care equipment was properly set and functioning, failure to ensure psychosocial wellbeing of residents after traumatic events, and failure to have a qualified activities professional.
Complaint Details
Multiple complaints substantiated including physical abuse by Resident #2 against other residents, neglect related to care and supervision, and failure to properly investigate and document incidents.
Severity Breakdown
SS=D: 5
SS=K: 1
SS=E: 2
SS=G: 1
SS=J: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to revise care plans timely to reflect resident needs and behaviors. | SS=D |
| Failure to prevent physical abuse by Resident #2 towards other residents, creating an immediate jeopardy situation. | SS=K |
| Failure to maintain accurate and complete investigations including obtaining signed witness statements. | SS=E |
| Failure to maintain accurate medical records regarding behavior monitoring documentation. | SS=D |
| Failure to ensure activities program was directed by a qualified licensed professional. | SS=D |
| Failure to ensure respiratory care equipment was set and functioning properly. | SS=G |
| Failure to ensure psychosocial wellbeing of a resident after traumatic event with follow-up and referrals. | SS=J |
| Failure to maintain effective QAPI program with proper data collection, monitoring, and follow-up. | SS=E |
| Failure to maintain patient care equipment in safe operating condition; oxygen concentrator overheated and malfunctioned. | SS=D |
Report Facts
Facility census: 65
Deficiencies cited: 9
Oxygen liter flow: 6
Oxygen liter flow: 3
One-on-one supervision hours: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Named in oxygen concentrator malfunction and investigation | |
| Certified Nursing Assistant | Named in neglect investigation for Resident #64 | |
| Social Worker | Conducted investigations and interviews related to neglect and abuse | |
| Director of Nursing | Acknowledged deficiencies and participated in interviews | |
| Administrator | Acknowledged deficiencies and participated in interviews | |
| Recreational Director | Not licensed as required for activities program |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 25, 2022
Visit Reason
The visit was conducted as an annual recertification and annual relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rule.
Findings
The facility, Stonerise Belmont, was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.
Inspection Report
Annual Inspection
Census: 61
Capacity: 68
Deficiencies: 12
Oct 19, 2022
Visit Reason
An unannounced recertification, relicensure and complaint investigation survey was conducted at Stonerise Belmont from October 16-19, 2022. The survey included complaint investigations with one complaint substantiated and related deficiencies cited.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, accuracy of comprehensive assessments, ADL care for dependent residents, pressure ulcer treatment, tube feeding management, respiratory care, sufficient nursing staff, medication storage and labeling, food safety and storage, garbage disposal, and medical record accuracy. Several residents were affected by these deficiencies, and corrective actions including education, audits, and policy reviews were implemented.
Complaint Details
Complaint #27293 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #27454 was substantiated with related deficiencies cited at F677 and F725.
Severity Breakdown
SS=D: 7
SS=E: 5
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure care was provided in a manner to promote resident dignity; a sign was posted in Resident #46's room with care instructions. | SS=D |
| Failure to complete accurate comprehensive assessments for hospice residents and those on anticoagulants (Residents #38, #44, #46). | SS=E |
| Failure to provide necessary ADL services such as showers and clothing changes for dependent residents (Resident #57 and others). | SS=D |
| Failure to provide necessary treatment and services to promote healing of pressure ulcers (Resident #55). | SS=D |
| Failure to ensure tube feeding residuals were checked and documented per physician orders (Resident #111). | SS=D |
| Failure to provide oxygen therapy at the prescribed flow rate (Resident #111). | SS=D |
| Failure to maintain sufficient nursing staff to meet resident needs and ensure quality care. | SS=E |
| Failure to store and administer drugs and biologicals properly, including use of expired insulin pen and lack of refrigerator temperature logs. | SS=E |
| Failure to serve food at appropriate temperatures and maintain palatability. | SS=E |
| Failure to label and date food items properly and maintain complete temperature logs for refrigerators, freezers, and dishwashers. | SS=D |
| Failure to properly contain garbage; dumpster was overfilled and uncovered. | SS=D |
| Failure to maintain accurate and complete medical records, including inaccurate POST forms, incorrect nutritional assessment weights, and inaccurate tube feed residual documentation. | SS=E |
Report Facts
Facility census: 61
Total capacity: 68
LPN staffing hours: 48
LPN staffing hours: 47.5
LPN staffing hours: 48.75
LPN staffing hours: 49.25
LPN staffing hours: 53.25
LPN staffing hours: 54.25
Expired insulin pen date: 2022
Food temperatures: 96
Food temperatures: 45.3
Food temperatures: 44.7
Food temperatures: 107
Food temperatures: 111
Food temperatures: 73
Food temperatures: 41.6
Tube feeding residual: 237
Tube feeding residual: 175
Oxygen flow rate: 1.5
Resident weight: 88
Incorrect resident weight: 184.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #65 | Minimum Data Set Registered Nurse | Verified incorrect MDS coding and oxygen flow rate error; involved in education and audits |
| Registered Nurse #88 | Registered Nurse | Confirmed MDS errors and oxygen flow rate error; involved in education and audits |
| Licensed Practical Nurse #26 | Licensed Practical Nurse | Identified expired insulin pen on medication cart |
| Director of Nursing | Director of Nursing | Provided multiple interviews confirming deficiencies and education plans |
| Food Services Director #56 | Food Services Director | Confirmed food temperature and labeling issues; responsible for food safety audits |
| Administrator | Facility Administrator | Provided interviews regarding staffing, restorative program, and education plans |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed POST form inaccuracies, tube feed residual documentation errors, and oxygen therapy issues |
Inspection Report
Life Safety
Deficiencies: 0
Oct 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2012, and to evaluate compliance with Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and was also found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
May 24, 2022
Visit Reason
An unannounced complaint investigation survey was conducted at Stonerise Belmont on May 24, 2022.
Findings
The facility was in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. Complaints #26499 and #26887 were unsubstantiated with no related or unrelated deficiencies cited.
Complaint Details
Complaint #26499 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #26887 was unsubstantiated with no related or unrelated deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 28, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on September 28, 2021.
Findings
The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 13
Jul 28, 2021
Visit Reason
An unannounced annual recertification/licensure survey was conducted at Stonerise Belmont from July 26-28, 2021 to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found out of substantial compliance with multiple deficiencies including resident rights violations related to staff rudeness and privacy, incomplete physician orders for Scope of Treatment forms, failure to provide privacy during medical treatments, failure to report verbal abuse allegations timely, failure to notify the Ombudsman of resident transfers, inaccurate MDS assessments, failure to assist residents with eating, failure to provide care consistent with professional standards, improper medication storage, and failure to address ongoing resident concerns about staff behavior.
Severity Breakdown
SS=E: 6
SS=D: 6
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to provide residents with respect and a dignified existence; staff used profanity and failed to knock before entering bathrooms. | SS=E |
| Facility failed to ensure physician orders for Scope of Treatment (POST) forms were completed correctly. | SS=E |
| Facility failed to provide personal privacy during medical treatments for one resident. | SS=D |
| Facility failed to report allegations of verbal abuse within required timeframes. | SS=D |
| Facility failed to provide Notice of Discharge to the State Long Term Care Ombudsman during resident transfers to hospital. | SS=E |
| Facility failed to provide bed hold notification to resident or representative before hospital transfer. | SS=D |
| Facility failed to accurately complete MDS section G (Eating) for one resident. | SS=D |
| Facility failed to assist a resident to eat by positioning properly and responding timely to call light. | SS=D |
| Facility failed to provide treatment and care in accordance with professional standards for multiple residents including pain management and psychotropic medication monitoring. | SS=E |
| Facility failed to ensure medications were stored at proper temperatures and removed expired or improperly stored medications. | SS=D |
| Facility failed to ensure colostomy care was provided by licensed nurses as per policy; unauthorized staff provided care. | SS=D |
| Facility failed to ensure hearing aids were functional and batteries replaced timely for a resident. | SS=D |
| Facility failed to identify, develop, and implement appropriate plans of action to correct ongoing resident concerns of negative staff behavior. | SS=E |
Report Facts
Residents affected: 10
Residents reviewed for POST form accuracy: 4
Residents transferred without Ombudsman notification: 3
Residents with bed hold notification missing: 1
Residents on psychotropic medication reviewed: 5
Residents interviewed for quality of care concerns: 7
Facility census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NA #77 | Named in findings for using profanity and rude behavior. | |
| Resident #21 | Interviewed about staff rudeness and negative behavior. | |
| Resident #54 | Interviewed about staff profanity and disrespect. | |
| Resident #34 | Interviewed about privacy violation in bathroom. | |
| Assistant Director of Nursing | ADON | Interviewed regarding education and deficiencies. |
| Interim Director of Nursing | DON | Provided education and acknowledged deficiencies. |
| Social Worker | Involved in POST form review and abuse reporting. | |
| RN #57 | Registered Nurse | Failed to provide privacy during treatment. |
| NA #54 | Nurse Aide | Provided unauthorized colostomy care. |
| LPN #76 | Licensed Practical Nurse | Replaced hearing aid batteries. |
| Corporate Nurse | Interviewed about QAPI and hearing aid battery availability. | |
| Dietary Manager | Provided education on food storage and temperature logs. | |
| Regional Vice President | RVP | Educated leadership on QAPI and resident concerns. |
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 28, 2021
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rule.
Findings
The facility, Stonerise Belmont, was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.
Inspection Report
Renewal
Census: 58
Deficiencies: 0
Jul 27, 2021
Visit Reason
The inspection was conducted as a recertification survey to assess the facility's compliance with regulatory requirements.
Findings
No deficiencies or citations were noted during the recertification survey. There were no complaints or substantiated issues reported.
Report Facts
Sample size: 80
Census: 58
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Jun 14, 2021
Visit Reason
An unannounced complaint investigation survey was conducted at Stonerise Belmont from June 14 to June 15, 2021.
Findings
The facility was found to be in substantial compliance with applicable regulations. Complaint #25541 was unsubstantiated with no related or unrelated deficiencies cited.
Complaint Details
Complaint #25541 was unsubstantiated with no related or unrelated deficiencies cited.
Report Facts
Complaint number: 25541
Census: 64
Inspection Report
Abbreviated Survey
Census: 55
Deficiencies: 0
Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on June 17, 2020.
Findings
The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Report Facts
Total census: 55
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 2, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility, Carehaven of Pleasants, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 13
May 8, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted from 05/06/19 through 05/08/19. Complaint reference #22461 was investigated concurrently with the annual survey.
Findings
The survey identified multiple deficiencies including failure to notify physician and Medical Power of Attorney of a resident fall in a timely manner, unsafe and unsanitary environment issues, inaccurate and incomplete resident assessments and care plans, medication administration documentation errors, and failure to follow physician orders for oxygen therapy. Pest control issues with spiders were also noted.
Complaint Details
Complaint reference #22461 was substantiated with related deficiencies cited at F580, F600, F610, and F684. The complaint involved failure to notify physician and Medical Power of Attorney of a resident fall and failure to investigate and report neglect.
Severity Breakdown
SS=D: 7
SS=E: 6
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to notify physician and Medical Power of Attorney of resident fall until two days later, resulting in delayed care and investigation. | SS=D |
| Failed to maintain a safe, clean, and comfortable environment including stained carpets, holes in walls, and dirty oxygen concentrator filters. | SS=E |
| Failed to provide resident the right to be free from neglect related to fall reporting and assessment. | SS=D |
| Failed to thoroughly investigate a fall with fracture and report accurate incident dates. | SS=D |
| Failed to complete accurate Minimum Data Set (MDS) assessments for falls, hospice services, and medication coding. | SS=D |
| Failed to provide resident a summary of their baseline care plan upon admission. | SS=D |
| Failed to develop and implement a comprehensive person-centered care plan including oxygen therapy for a resident. | SS=D |
| Failed to include appropriate parties in care plan meetings and failed to revise care plans timely. | SS=E |
| Failed to accurately document medication administration for a resident. | SS=D |
| Failed to provide respiratory care consistent with physician orders for oxygen therapy. | SS=E |
| Failed to label and date drugs and biologicals properly in medication storage areas. | SS=E |
| Failed to maintain a safe and sanitary environment including presence of dietary supplement in medication refrigerator and gloves on floors in resident rooms. | SS=E |
| Failed to maintain an effective pest control program resulting in presence of spiders in multiple resident rooms. | SS=E |
Report Facts
Facility census: 54
Deficiency count: 13
Fall notification monitoring: 5
Fall notification monitoring duration: 3
MDS audit frequency: 5
MDS audit duration: 3
Care plan audit frequency: 5
Care plan audit duration: 3
Medication administration monitoring frequency: 10
Medication administration monitoring duration: 3
Food service monitoring frequency: 5
Food service monitoring duration: 3
Pest control treatment frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #85 | Licensed Practical Nurse | Named in failure to report resident fall and delayed notification to physician and MPOA |
| Director of Nursing | Named in multiple findings including fall notification, care plan compliance, medication administration, and oxygen therapy compliance | |
| MDS Nurse #23 | Registered Nurse / MDS Coordinator | Named in findings related to inaccurate Minimum Data Set assessments |
| CNA #84 | Certified Nursing Assistant | Named in reporting resident fall to LPN #85 |
| Administrator | Named in reporting and re-investigation of resident fall incident | |
| Food Service Director #60 | Named in food storage and labeling deficiencies | |
| LPN #202 | Licensed Practical Nurse | Named in medication labeling deficiencies |
| Activities Director #50 | Named in failure to invite residents to care plan meetings | |
| Housekeeping Staff | Named in cleaning and pest control deficiencies | |
| Environmental Services Director | Named in pest control and environmental sanitation deficiencies |
Inspection Report
Life Safety
Deficiencies: 0
May 7, 2019
Visit Reason
The inspection was conducted to assess the facility's compliance with NFPA 101, Life Safety Code, 2012, and applicable Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Oct 9, 2018
Visit Reason
An unannounced complaint investigation was conducted from October 9, 2018 to October 10, 2018 at Carehaven of Pleasants for Complaint Reference #21007.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Complaint Details
Complaint Reference #21007 was investigated and found unsubstantiated with no deficiencies identified.
Report Facts
Census: 58
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 9, 2018
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility, Carehaven of Pleasants, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 6
May 24, 2018
Visit Reason
An unannounced annual recertification and relicensure survey was conducted at Care Haven of Pleasants from May 21, 2018 through May 24, 2018.
Findings
The facility was found deficient in multiple areas including failure to revise care plans when residents' conditions changed, failure to follow physician orders, incomplete medical records for hospice residents, failure to maintain proper infection control practices, failure to follow menu portion sizes and notify residents of menu changes, and failure to maintain timely and complete drug regimen review policies.
Severity Breakdown
SS=E: 2
SS=D: 3
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to revise residents' care plans when conditions or interventions changed for six residents (#12, #24, #25, #45, #62, #64). | SS=E |
| Failure to provide bedside commode as ordered for Resident #24. | SS=D |
| Failure to maintain policies and procedures for monthly drug regimen review including time frames for review and action. | SS=F |
| Failure to follow menu portion sizes and notify residents of menu changes. | SS=E |
| Failure to maintain complete and accurate medical records for hospice residents #6 and #64, including wound and orthopedic device documentation. | SS=D |
| Failure to maintain effective infection prevention and control program; improper wound care and hand hygiene observed. | SS=D |
Report Facts
Residents reviewed for care plans: 31
Residents with care plan deficiencies: 6
Facility census: 58
Falls for Resident #45: 6
Days for physician review of irregularities: 14
Days for escalation of unreviewed irregularities: 21
Portion size: 0.5
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #18 | Licensed Practical Nurse | Observed performing wound care with improper infection control techniques. |
| Director of Nursing | Director of Nursing | Interviewed and acknowledged care plan and infection control deficiencies. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed and acknowledged care plan and infection control deficiencies; involved in audits. |
| RN #84 | Registered Nurse Hospice Staff | Interviewed regarding lack of hospice documentation in medical record for Resident #6. |
| LPN #23 | Licensed Practical Nurse | Present during hospice interview; agreed medical record should contain hospice care documentation. |
| MDS Coordinator #80 | Minimum Data Set Coordinator | Acknowledged care plan for Resident #25 was not up to date. |
| MDS Coordinator #27 | Minimum Data Set Coordinator | Acknowledged care plan for Resident #64 did not address Stage 2 pressure ulcer. |
| Director of Clinical Pharmacy Services | Director of Clinical Pharmacy Services | Reviewed and revised drug regimen review policy. |
| Dietary Manager | Dietary Manager | Interviewed about menu portion size and notification deficiencies; responsible for audits. |
| Staff Development Coordinator | Staff Development Coordinator | Provided infection control education to employee #18. |
Inspection Report
Life Safety
Deficiencies: 0
May 22, 2018
Visit Reason
The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and was also found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Plan of Correction
Deficiencies: 1
May 4, 2017
Visit Reason
The document is a plan of correction related to a Quality Indicator and Licensure Survey for a long term care facility, accepted in lieu of an onsite revisit.
Findings
The facility, Carehaven of Pleasants, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and rules in a language they understand, including notice of Medicaid benefits and charges. | Level C |
Report Facts
Survey completion date: May 4, 2017
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 3
Apr 6, 2017
Visit Reason
An unannounced annual Quality Indicator Survey, State Licensure Survey, and a Complaint Investigation were conducted at Carehaven of Pleasants from April 3, 2017 to April 6, 2017.
Findings
The facility was found deficient in several areas including sanitary food storage and preparation, proper labeling and storage of medications, and maintaining complete and accurate medical records. The complaint investigation was unsubstantiated.
Complaint Details
Complaint Investigation #17575 was unsubstantiated.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility failed to prepare and store food under safe and sanitary conditions; the ice machine drain was incorrectly installed and non-food items were stored in the resident's nourishment refrigerator. | SS=E |
| A multi-dose vial of tuberculin solution was opened, partially used, and not dated to indicate when it was initially opened. | SS=E |
| The facility failed to maintain accurate, complete, and organized clinical information about each resident that was readily accessible for resident care; Resident #37's medical record lacked any information related to a recent acute care stay. | SS=D |
Report Facts
Facility census: 60
Survey dates: 4
Survey sample size: 23
Deficiency citations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Supervisor #44 | Interviewed regarding ice machine drainage pipe and food storage | |
| Nurse Aide #27 | Nurse Aide | Interviewed regarding items stored in nourishment refrigerator |
| Licensed Practical Nurse #38 | LPN | Observed medication room refrigerator and identified unlabeled tuberculin vial |
| Health Information Management Director #45 | Director | Reviewed medical record and confirmed lack of acute care stay documentation |
| Director of Nursing | Director of Nursing | Responsible for educating licensed nursing staff on drug records, labeling, and storage |
Inspection Report
Life Safety
Census: 60
Deficiencies: 4
Apr 4, 2017
Visit Reason
The inspection was conducted to evaluate the facility's compliance with NFPA standards related to sprinkler system installation, building system risk assessment, and essential electrical systems as part of a life safety code survey.
Findings
The facility failed to provide sprinkler protection in accordance with NFPA 13 and 101, failed to conduct a documented formal risk assessment of building systems per NFPA 99, failed to categorize the essential electrical system according to NFPA 99 and 101, and failed to provide a remote annunciator that is storage battery powered for the generator as required by NFPA 99. These deficiencies were discussed with the Administrator and Maintenance Director and plans for correction were initiated.
Severity Breakdown
SS=C: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide sprinkler protection in accordance with NFPA 13 and 101; linen cart alcove next to resident room 423 was not sprinkled as required. | SS=C |
| Failed to conduct a documented formal risk assessment on building systems and categorize those systems in accordance with NFPA 99. | SS=C |
| Failed to categorize the essential electrical system in accordance with NFPA 99 and 101. | SS=C |
| Failed to provide a remote annunciator that is storage battery powered for the essential electric system generator in accordance with NFPA 99. | SS=C |
Report Facts
Facility Census: 60
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Director | Named in relation to corrective actions and education on NFPA standards | |
| Administrator | Discussed deficiencies with surveyors | |
| Maintenance Director | Discussed deficiencies with surveyors | |
| Chief Executive Officer | Contacted contractors for correction quotes |
Inspection Report
Life Safety
Deficiencies: 0
Feb 11, 2016
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 0
Feb 10, 2016
Visit Reason
An unannounced annual Quality Indicator Survey was conducted at Carehaven of Pleasants from February 8, 2016 through February 10, 2016.
Findings
The facility was found to be in substantial compliance with Federal Requirements 483.10 through 483.75 and Title 64, Legislative Rules, West Virginia Division of Health Series 13, Nursing Home Licensure Rule. The facility was free of any health related deficiencies.
Report Facts
Survey sample size: 25
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Mar 9, 2015
Visit Reason
An unannounced complaint investigation was conducted at Care Haven of Pleasants from March 9, 2015 through March 11, 2015 for Complaint Reference #12783.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Complaint Details
The allegations were unsubstantiated and no related or unrelated deficient practices were identified.
Report Facts
Sample size: 9
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 26, 2015
Visit Reason
The document is a plan of correction related to a Quality Indicator and Licensure Survey for a long term care facility, accepted in lieu of an onsite revisit.
Findings
The facility, Carehaven of Pleasants, is in substantial compliance with 42 CFR Part 483 and state nursing home licensure rules, with previously cited deficient practices addressed through credible evidence and plans of correction.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility, including notice of Medicaid benefits and charges. | Level C |
Report Facts
Survey completion date: Jan 26, 2015
Plan of correction date: Mar 1, 2011
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 11
Dec 18, 2014
Visit Reason
An unannounced annual Quality Indicator and Licensure Survey was conducted at Carehaven of Pleasants from December 8, 2014 to December 18, 2014 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including comprehensive assessments, investigation and reporting of abuse allegations, care planning, medication administration, infection control, immunizations, and staff competency. Specific issues included inaccurate resident assessments, failure to report abuse allegations, incomplete care plans, failure to administer medications as ordered, improper infection control practices, delayed influenza vaccination, and incomplete criminal background checks for contracted therapy staff.
Severity Breakdown
SS=D: 5
SS=E: 6
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to conduct an accurate comprehensive assessment for a resident on a turn and repositioning program. | SS=D |
| Failed to ensure criminal background checks were completed and abuse allegations reported. | SS=E |
| Failed to develop an interim care plan related to pre-dialysis care for a newly admitted resident. | SS=D |
| Failed to revise care plans related to residents' status changes and/or needs for pain, accidents, activities and dialysis. | SS=D |
| Failed to provide necessary care and services to attain or maintain highest practicable well-being including pain management, dialysis monitoring, and medication administration. | SS=E |
| Failed to maintain an effective influenza and pneumococcal immunization program. | SS=D |
| Failed to maintain an infection control program; improper storage of bedpans and failure to sanitize hands during medication administration and incontinence care. | SS=E |
| Failed to ensure nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs, including peri care. | SS=E |
| Failed to maintain accurate and complete medical records regarding notification of room changes. | SS=D |
| Failed to ensure residents' drug regimens were free from unnecessary drugs; Ativan was administered without adequate rationale, monitoring, or dosing parameters. | SS=E |
| Quality Assessment and Assurance committee failed to identify and act upon quality deficiencies related to contracted therapy staff background checks. | SS=E |
Report Facts
Survey sample size: 30
Facility census: 63
Deficiency counts: 11
Employees reviewed for competency: 5
Employees with missing competency checks: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding resident assessments and care planning | |
| Administrator | Interviewed regarding QA committee and background checks | |
| Assistant Director of Nursing | Interviewed regarding influenza vaccination process | |
| Registered Nurse Consultant | Provided information on therapy company background checks | |
| Social Worker | Interviewed regarding room change notification | |
| Licensed Practical Nurse | Observed and interviewed regarding medication administration and pain management | |
| Nursing Assistants | Observed and interviewed regarding peri care and incontinence management |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Dec 18, 2014
Visit Reason
An unannounced complaint investigation (#12299) was conducted at Carehaven of Pleasants from 12/15/14 to 12/18/14.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Complaint Details
The allegations were unsubstantiated and no related or unrelated deficient practices were identified.
Inspection Report
Life Safety
Deficiencies: 0
Dec 17, 2014
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
May 14, 2014
Visit Reason
The inspection was conducted as a complaint survey following complaint #11280 regarding no state ID in shell.
Findings
The complaint was found to be not substantiated with no citations issued. The medication error rate was 0%.
Complaint Details
Complaint #11280 regarding no state ID in shell was investigated and found not substantiated.
Report Facts
Sample size: 9
Medication error rate: 0
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 24, 2013
Visit Reason
The document is a plan of correction related to deficiencies identified during a prior inspection of Belmont Healthcare Center.
Findings
The report references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Report Facts
Provider/Supplier Identification Number: 515191
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Aug 29, 2013
Visit Reason
The inspection was conducted in response to allegations of neglect and abuse reported in a letter concerning lack of care for three residents (#5, #30, and #84). The facility was investigated for failure to report these allegations to the appropriate State agencies.
Findings
The facility failed to immediately report allegations of neglect involving three residents to the required State agencies. Investigations were conducted internally, but the results were not reported as required. The Administrator and Director of Nursing acknowledged awareness of the allegations but did not report them, believing others had done so. The complaint was unsubstantiated with no citations issued.
Complaint Details
Allegations of neglect were made in a letter dated 08/21/13 regarding lack of care for Resident #5 (Cellulitis), ineffective pain control for Resident #30, and delayed treatment for Resident #84's urinary tract infection. The facility investigated but failed to report these allegations to State agencies as required. The complaint was unsubstantiated with no citations.
Severity Breakdown
SS=B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure all allegations of abuse/neglect were immediately reported to the appropriate State agencies for three residents. | SS=B |
| Failed to implement the facility's abuse and neglect reporting policy requiring immediate reporting of allegations and investigation results to State agencies. | SS=B |
Report Facts
Facility Census: 60
Residents reviewed: 25
Residents with unreported allegations: 3
Complaint Reference: 13194
Complaint Reference: 8630
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding allegations of neglect and failure to report | |
| Director of Nursing | Interviewed regarding allegations of neglect and failure to report |
Inspection Report
Life Safety
Deficiencies: 0
Aug 27, 2013
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 24, 2012
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Belmont Healthcare Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Sep 5, 2012
Visit Reason
The inspection was conducted as a substantiated complaint investigation regarding the facility's compliance with notice requirements before transfer or discharge and bed-hold policy notification.
Findings
The facility failed to provide a written notice of discharge and the resident's right to appeal the discharge to the State for one resident. Additionally, the facility did not provide timely written information regarding the bed-hold policy to the resident's medical power of attorney within 24 hours of transfer.
Complaint Details
Complaint Reference: 12203 / 7300. Substantiated complaint record with citations. Complaint investigation conducted from 2012-09-04 to 2012-09-05.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide written notice of discharge and resident's right to appeal the discharge to the State. | SS=D |
| Failure to provide written information regarding bed-hold policy in a timely manner (within 24 hours of transfer). | SS=D |
Report Facts
Facility census: 67
Residents reviewed: 6
Residents with deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Employee #16 who gave verbal notification of discharge to Resident #69 |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 28, 2012
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of Belmont Healthcare Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | SS=C |
Report Facts
Deficiency ID: 156
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 13, 2012
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Belmont Healthcare Center.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Report Facts
Deficiency ID: 156
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Jun 4, 2012
Visit Reason
The inspection was conducted in response to a complaint (Reference: 12055 / 7098) from 06/04/12 to 06/05/12.
Findings
The facility failed to ensure safety in two rooms by leaving construction tools and supplies unattended and accessible to residents. Specifically, construction equipment was found in an unoccupied room with the door open and unattended, and caulking materials were found unattended in an occupied resident room.
Complaint Details
Complaint Reference: 12055 / 7098. The complaint was unsubstantiated but resulted in an unrelated citation.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Unattended construction equipment (saw, hammers, electrical cords) in an unoccupied room with the door open and unattended. | SS=E |
| Unattended caulking and a full caulking gun in an occupied resident room (#213). | SS=E |
Report Facts
Facility census: 57
Number of rooms observed: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding awareness of open door with construction equipment | |
| Administrator | Interviewed regarding presence of caulking materials in resident room |
Inspection Report
Life Safety
Deficiencies: 0
Apr 27, 2012
Visit Reason
The inspection was conducted to determine the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the Life Safety Code provisions.
Inspection Report
Routine
Census: 61
Deficiencies: 9
Apr 26, 2012
Visit Reason
Quality Indicator & Licensure Survey conducted from 04/23/12 to 04/26/12 to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights, inadequate social services, failure to develop and revise care plans appropriately, improper medication administration, failure to follow dietary menus, and unsanitary food handling practices.
Severity Breakdown
SS=D: 7
SS=E: 1
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to allow one resident to exercise rights and gave a 30-day notice for refusing care without proper investigation. | SS=D |
| Failed to ensure resident's right to refuse treatment was respected and alternative treatments were not offered. | SS=D |
| Failed to allow resident to make choices regarding who provides care. | SS=D |
| Failed to notify residents before room changes due to construction. | SS=D |
| Failed to provide medically-related social services addressing needs of residents including depression, refusal of treatment, and financial/legal assistance. | SS=D |
| Failed to develop and revise comprehensive care plans reflecting resident needs and preferences, including discharge plans. | SS=D |
| Failed to provide care and services to ensure highest practicable physical well-being; inhaled respiratory medications were administered improperly without proper spacing or mouth rinsing. | SS=D |
| Failed to follow planned menu for pureed diets; used incorrect scoop size resulting in smaller portions than planned. | SS=E |
| Failed to ensure food was prepared and served under sanitary conditions; staff failed to use proper handwashing techniques and contaminated clean hands. | SS=F |
Report Facts
Facility census: 61
Residents on pureed diets: 16
Sample residents: 33
Inhaled medications administered: 3
Inhalations of ProAir: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #78 | Social Worker/Admission Coordinator | Involved in social service deficiencies and care planning for Residents #8, #73, and #78 |
| Employee #97 | Treatment Nurse | Interviewed regarding Resident #78's wound treatment refusals and communication with wound care center and physician |
| Employee #100 | Administrator | Interviewed regarding meetings with Resident #78, room change policies, and social service issues |
| Employee #83 | Evening Shift Nurse | Interviewed regarding Resident #78's preferences for caregivers |
| Employee #25 | Licensed Nurse | Observed administering inhaled medications to Resident #38 |
| Employee #16 | Dietary Staff Member | Observed serving incorrect scoop size for pureed beef and improper handwashing |
| Employee #9 | Dietary Staff Member | Observed improper handwashing and contamination of hands |
| Employee #53 | Dietary Staff Member | Observed improper handwashing and contamination of hands |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 10, 2012
Visit Reason
This document is a plan of correction submitted in response to a prior inspection, indicating acceptance of credible evidence and corrective actions.
Findings
The report notes acceptance of the plan of correction and credible evidence submitted by the facility, with no new deficiencies detailed in this document.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Jan 17, 2012
Visit Reason
The inspection was conducted as a complaint investigation regarding an incident involving Resident #22 who suffered a fracture to her left wrist/arm, with concerns about the facility's failure to properly investigate the incident and document it accurately.
Findings
The facility failed to thoroughly investigate an incident resulting in a fracture of Resident #22's arm and did not gather statements or conduct an adequate investigation to rule out abuse. Additionally, the medical record documentation was incomplete and inaccurate, with nursing notes reflecting statements inconsistent with the resident's physical and communication abilities.
Complaint Details
Complaint Reference ID: 11295. Substantiated complaint record with citations. The complaint involved failure to investigate an incident resulting in a fracture and failure to maintain accurate medical records.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to investigate an incident resulting in a fracture of Resident #22's arm to rule out abuse. | SS=D |
| Failure to maintain complete and accurate clinical records for Resident #22, including inaccurate nursing notes regarding the incident and resident's condition. | SS=D |
Report Facts
Facility Census: 63
Incident Date: Oct 3, 2011
Date of nursing note: Oct 4, 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Nurse Supervisor | Wrote nursing note based on report from another nurse without personal assessment; did not investigate incident |
| Employee #86 | Director of Nursing | Interviewed regarding incident and documentation; confirmed lack of investigation and inaccurate nursing notes |
| Employee #38 | Nursing Assistant | Provided care to resident; confirmed resident's limited movement and communication |
| Employee #87 | Administrator | Reported incident to state agency; confirmed no investigation was conducted |
| Employee #88 | Occupational Therapy Assistant | Provided therapy to resident; confirmed resident's limited mobility and communication |
| Employee #54 | Restorative Nursing Assistant | Provided passive range of motion therapy; confirmed no therapy was done on injured arm during painful period |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 5
Aug 4, 2010
Visit Reason
Complaint investigation triggered by complaint reference #10203 regarding injuries of unknown origin and allegations of abuse and neglect at Belmont Healthcare Center.
Findings
The facility failed to protect Resident #17 from multiple injuries of unknown origin to her right upper extremity, failed to report allegations of abuse and neglect involving five residents to Adult Protective Services and the State Ombudsman, failed to develop a comprehensive care plan to prevent recurrent injuries for Resident #17, failed to ensure Resident #17's medication regimen was free from unnecessary drugs and used within recommended guidelines, and failed to ensure the attending physician documented progress notes and treatment plans following significant trauma to Resident #17.
Complaint Details
Complaint reference #10203 was substantiated with deficiencies cited related to injuries of unknown origin and failure to report abuse/neglect allegations involving residents #17, #19, #49, #54, and #3.
Severity Breakdown
G: 2
E: 2
D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to protect Resident #17 from multiple injuries of unknown origin to right upper extremity. | G |
| Failure to report allegations of abuse/neglect involving five residents to Adult Protective Services and State Ombudsman. | E |
| Failure to develop a comprehensive care plan to prevent recurrent injuries of unknown origin for Resident #17. | D |
| Failure to ensure Resident #17's drug regimen was free from unnecessary drugs, including excessive doses of Ativan and inappropriate use of Risperdal M-tab. | G |
| Failure to ensure attending physician wrote progress notes and documented treatment plan following significant trauma to Resident #17's right arm. | E |
Report Facts
Facility census: 65
Bruise size: 4
Skin tear size: 3
Skin tear size: 1.5
Ativan dosage: 6
Ativan dosage: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reported attending physician visited Resident #17 but did not document assessment or treatment plan | |
| Registered Nurse | Reported attending physician visited Resident #17 but did not document assessment or treatment plan | |
| Social Worker | Confirmed injuries of unknown origin were not reported to APS or State Ombudsman | |
| Administrator | Confirmed injuries of unknown origin were not reported to APS or State Ombudsman | |
| Assistant Director of Nursing | Confirmed Resident #17 had potential to receive excessive Ativan dose and psychiatrist did not document risk-benefit assessment |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 31, 2010
Visit Reason
The inspection was conducted in response to complaint reference #10084.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Complaint Details
Complaint reference #10084 was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 16, 2010
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #10064.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #10064 was unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 1
Jan 13, 2010
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medical record accuracy, and documentation practices in the facility.
Findings
The facility failed to maintain complete and accurate medical records for two residents, including inadequate documentation of resident behaviors and inaccurate transcription of physician orders. The director of nurses acknowledged these deficiencies and the failure to document agreement with care plans.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medical records were incomplete and inaccurate for two residents, including failure to document frequency of behaviors and notification of medical power of attorney, and inaccurate transcription of physician orders. | Level D |
Report Facts
Facility census: 62
Residents sampled: 9
Residents with deficient records: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | DON | Acknowledged incomplete and inaccurate medical records and failure to document MPOA agreement |
Inspection Report
Life Safety
Deficiencies: 0
Nov 3, 2009
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 10
Oct 22, 2009
Visit Reason
The inspection was an annual survey to assess compliance with federal regulations for nursing facilities, including investigation of allegations of abuse, medication administration, infection control, and resident care.
Findings
The facility was found deficient in multiple areas including failure to properly investigate and report allegations of abuse, failure to provide adequate pre-meal activities, medication errors including incorrect catheter size and missed medications, failure to complete required pre-admission screening, inadequate pain management, insufficient fall prevention measures, improper nurse staffing posting, medication administration errors, and inadequate infection control practices.
Severity Breakdown
SS=C: 2
SS=D: 3
SS=E: 2
SS=F: 2
SS=G: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to properly investigate and report allegations of abuse and injuries of unknown origin for Resident #36. | SS=D |
| Failure to provide pre-meal activities to enhance the dining environment affecting approximately 20 residents. | SS=E |
| Failure to ensure nursing services met professional standards including incorrect Foley catheter size insertion and failure to administer medications as ordered for Residents #33, #30, and #17. | SS=E |
| Failure to complete required pre-admission screening after initial certification period expired for Resident #34. | SS=D |
| Failure to provide care and services to ensure highest practicable well-being; Resident #29 exhibited pain that was not promptly addressed. | SS=G |
| Failure to maintain a resident environment free of accident hazards and provide adequate supervision and assistive devices to prevent accidents; Resident #34 had two falls from bed within three days. | SS=D |
| Failure to post nurse staffing data in a clear and readable format accessible to residents and visitors. | SS=C |
| Failure to ensure accurate pharmaceutical services; excess doses of medications found on hand indicating residents did not receive medications as ordered. | SS=F |
| Failure to ensure medication regimens were free from unnecessary drugs; Resident #36 received antipsychotic medication without adequate indication. | SS=D |
| Failure to maintain an effective infection control program; Resident #34 with vancomycin resistant enterococcus infection was not properly isolated and infection control measures were not followed. | SS=F |
Report Facts
Facility census: 65
Residents reviewed: 13
Excess Depakote doses Resident #33: 35
Excess Depakote doses Resident #30: 12
Excess medication doses Resident #17: 39
Residents on contact isolation: 5
Personal protective gowns purchased: 50
Residents affected by pre-meal activity deficiency: 20
Falls Resident #34: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #77 | Administrator | Named in abuse investigation and staffing posting findings |
| Employee #1 | Director of Nursing | Named in abuse investigation and medication administration findings |
| Employee #54 | Social Worker | Named in abuse investigation and pre-admission screening findings |
| Employee #10 | Assisted with medication cart audits | |
| Employee #14 | Assisted with medication cart audits | |
| Employee #79 | Consultant Pharmacist | Interviewed regarding medication administration issues |
| Employee #40 | Identified infection control practices | |
| Employee #74 | Director of Housekeeping | Interviewed regarding infection control supplies |
| Employee #6 | Interviewed regarding Resident #29's pain and chair evaluation |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Feb 26, 2009
Visit Reason
The inspection was conducted as a complaint investigation triggered by substantiated complaints regarding infection control and outbreak management at the facility.
Findings
The facility failed to establish and maintain an effective infection control program, resulting in a respiratory infection outbreak affecting 33 residents between 01/08/09 and 02/24/09. The facility did not track or recognize the outbreak until intervention by the local health department (LHD) on 02/16/09, failed to report the outbreak timely as required by state law, and the Quality Assessment and Assurance (QAA) committee failed to identify and address these deficiencies.
Complaint Details
Complaint references #9062 and #9073 were substantiated with deficiencies cited. Complaint reference #9048 was unsubstantiated with no related deficiencies.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to establish and maintain an infection control program that investigates, controls, and prevents infections, including failure to track and analyze infection incidents and identify outbreaks. | SS=F |
| Failure to immediately report an outbreak or cluster of respiratory infections to the local health department in accordance with state law. | SS=F |
| Failure of the Quality Assessment and Assurance (QAA) committee to identify and take corrective actions regarding the infection control deficiencies and outbreak. | SS=F |
Report Facts
Residents affected by respiratory infection: 33
Facility census: 54
Residents exhibiting respiratory infection signs on specific dates: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Acknowledged the facility had not tracked or recognized the outbreak until after LHD intervention on 02/16/09. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 9, 2008
Visit Reason
The inspection was conducted in response to complaint references #2-8328 and #2-8336.
Findings
The complaint investigations were unsubstantiated with no deficiencies cited.
Complaint Details
Complaint references #2-8328 and #2-8336 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 30, 2008
Visit Reason
This document is a plan of correction related to deficiencies identified in a prior inspection of Belmont Healthcare Center.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 9
Oct 9, 2008
Visit Reason
Complaint investigation triggered by multiple complaint references (#2-8147, #2-8253, #2-8263, and #2-8287) regarding neglect and other issues at the facility.
Findings
The facility was found to have multiple deficiencies including neglect due to inadequate staffing and staff leaving the building for breaks simultaneously, failure to report incidents of neglect, medication administration without physician orders, failure to provide scheduled showers and bed linen changes, delays in responding to call lights causing urinary incontinence, failure to analyze skin tear incidents, insufficient nursing staff, and failure to provide timely and properly heated meals and bedtime snacks.
Complaint Details
Complaint references #2-8147, #2-8253, #2-8263, and #2-8287 were substantiated with deficiencies cited related to neglect, failure to report incidents, and inadequate care.
Severity Breakdown
E: 4
D: 4
F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Five registered long-term care nursing assistants left the facility simultaneously for breaks, leaving insufficient staff to care for 61 residents; nurse call system auditory alarm was turned off. | E |
| Failure to immediately report and thoroughly investigate neglect incidents involving staff breaks and nurse call system alarm silencing. | D |
| Medication administered without a physician's order for Resident #33. | D |
| Thirteen of twenty-one residents did not receive scheduled showers due to low staffing; bed linens not changed for seven residents. | E |
| Resident #20 experienced delays in assistance to the commode leading to urinary incontinence. | D |
| Facility failed to evaluate and analyze occurrences of skin tears and implement interventions to reduce recurrence affecting 14 residents. | E |
| Insufficient nursing staff to meet resident care needs, including showering, linen changes, and timely meal service. | F |
| Meal trays delivered late and at improper temperatures; residents reported cold food and late meal delivery. | D |
| Bedtime snacks were not provided to residents; snacks were discarded unopened in the nursing unit pantry garbage. | E |
Report Facts
Facility census: 61
Number of RLTCNAs leaving for break simultaneously: 5
Residents affected by missed showers: 13
Skin tears reported: 14
Skin tears reported: 11
Residents affected by skin tears: 14
Residents not having bed linens changed: 7
Residents reporting delayed meal trays: 2
Residents waiting over 30 minutes for call light response: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Director of Nursing (DON) | Interviewed regarding nurse call system alarm and staff break issues. |
| Employee #33 | Shower Aide | Interviewed about being pulled to floor due to low staffing and incomplete showers. |
| Employee #4 | Assistant Director of Nursing (ADON) | Reported meal trays were delivered late due to lack of staff. |
| Dietary Manager | Interviewed about meal tray delivery and bedtime snack issues. |
Inspection Report
Life Safety
Census: 61
Deficiencies: 1
Aug 21, 2008
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically the maintenance and operation of the fire alarm system.
Findings
The facility failed to maintain all components of the fire alarm system in accordance with NFPA 72 standards. Specifically, when the primary and secondary phone lines were disconnected from the fire alarm automatic dialing system, no trouble signal was sent to the fire alarm annunciator panel as required.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain all components of the fire alarm system in accordance with NFPA 72, including lack of trouble signal when phone lines were disconnected. | SS=F |
Report Facts
Facility census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| facility environmental director | Interviewed regarding fire alarm system issues |
Inspection Report
Routine
Census: 66
Deficiencies: 17
Jul 15, 2008
Visit Reason
Routine inspection of Belmont Healthcare Center to assess compliance with federal regulations including resident rights, care planning, staff treatment, infection control, and facility conditions.
Findings
The facility was cited for multiple deficiencies including failure to post required resident rights and survey results, inadequate investigation and reporting of complaints, failure to ensure dignified care and timely assistance, unresolved resident grievances, ineffective social services access, incomplete resident assessments, delayed MDS submissions, incomplete care plans, failure to prevent pressure sores, inadequate hydration, unsanitary food service conditions, and improper hand hygiene by staff.
Severity Breakdown
SS=C: 4
SS=D: 7
SS=E: 3
SS=B: 1
SS=F: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to post addresses of State agencies and complaint filing information as required. | SS=C |
| Failure to post survey results in a place accessible to residents. | SS=C |
| Failure to thoroughly investigate and report allegations of abuse and neglect. | SS=D |
| Failure to provide dignified dining experience and timely toileting assistance. | SS=C |
| Failure to resolve resident complaints about cold food. | SS=C |
| Failure to act on resident council grievances about early morning disturbances. | SS=D |
| Social worker's dog gate at office door created barrier to resident communication and access. | SS=E |
| Failure to record dates on resident assessment protocols (RAPs) for care planning decisions. | SS=B |
| Failure to complete MDS assessments within required timeframes for one resident. | SS=D |
| Care plans did not address known resident problems including anxiety and pressure sore prevention. | SS=D |
| Residents not invited to or included in care plan meetings. | SS=E |
| Failure to prevent pressure sores by turning resident every two hours as ordered. | SS=D |
| Failure to ensure physician-ordered hand splinting was applied to prevent decline in range of motion. | SS=D |
| Failure to address significant unplanned weight gain in resident care plan. | SS=D |
| Failure to provide water at bedside at all times for multiple residents. | SS=E |
| Ice machine in dietary department was not maintained in a sanitary manner, with lime deposits present. | SS=F |
| Staff failed to wash hands between residents when delivering food trays, contaminating food. | SS=E |
Report Facts
Facility census: 66
Weight gain: 36
Residents without water at bedside: 18
Residents sampled: 13
Residents in confidential group meeting: 8
Residents with care plan deficiencies: 2
Residents with RAP date issues: 4
Residents with delayed MDS: 1
Residents with pressure sore issues: 1
Residents with hand splinting issues: 1
Residents with unplanned weight gain: 1
Residents observed without water: 18
Ice machine cleaning issue: 1
Staff handwashing failure: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #30 | Nurse Aide | Failed to wash hands between residents and contaminated food |
| Employee #1 | Director of Nursing | Confirmed multiple deficiencies including care plan and complaint investigations |
| Employee #4 | Registered Nurse | Scheduled review for resident weight gain |
| Dietary Manager | Verified ice machine lime deposits and acknowledged food temperature issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 4, 2007
Visit Reason
The inspection was conducted in response to complaint reference #2-7267.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-7267 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Deficiencies: 1
Jun 12, 2007
Visit Reason
The document is a paper revisit inspection conducted at Belmont Healthcare Center to review compliance and deficiencies.
Findings
The report includes a statement of deficiencies related to resident rights and notification requirements, with a focus on informing residents of their rights and services in writing and orally.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to inform residents both orally and in writing of their rights and all rules and regulations governing resident conduct and responsibilities during their stay. | Level C |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 12, 2007
Visit Reason
Paper Revisit to review previously identified deficiencies and the facility's plan of correction.
Findings
The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements. Specific deficiencies are cited but detailed findings are not fully provided in this excerpt.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay. | Level C |
Report Facts
Survey completion date: Jun 12, 2007
Inspection Report
Life Safety
Deficiencies: 0
Apr 19, 2007
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition based on the review.
Inspection Report
Life Safety
Deficiencies: 0
Apr 19, 2007
Visit Reason
The inspection was conducted to review the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 11
Apr 12, 2007
Visit Reason
Complaint investigation conducted concurrently with the facility's Federal Medicaid certification survey and State licensure inspection, triggered by complaint reference #2-7059.
Findings
The facility was found deficient in multiple areas including failure to inform residents of surrogate decision makers, inadequate activities programming, incomplete social services documentation, failure to ensure cardiac pacemaker checks and constipation interventions, insufficient restorative nursing services, unsafe dining supervision leading to choking risk, unnecessary drug use, failure to post nurse staffing data, incorrect food portioning, improper food storage temperatures, and failure to complete required laboratory monitoring for residents on diuretics.
Complaint Details
Complaint reference #2-7059 was unsubstantiated with no related deficiencies cited. The investigation was conducted concurrently with the Federal Medicaid certification survey and State licensure inspection.
Severity Breakdown
SS=B: 2
SS=C: 1
SS=D: 5
SS=E: 2
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure residents were informed that a surrogate decision maker would act on their behalf. | SS=B |
| Failed to develop and implement a program of group and individual activities to meet residents' needs. | SS=E |
| Failed to provide medically-related social services including updating resident rights notification annually and completing social service progress notes quarterly. | SS=B |
| Failed to ensure cardiac pacemaker was checked and interventions to prevent constipation were provided. | SS=D |
| Failed to provide restorative nursing services as ordered and develop goals to evaluate effectiveness. | SS=D |
| Failed to maintain a safe environment during meal services; resident with chewing problems choked due to lack of supervision. | SS=D |
| Failed to ensure medications were not given in excessive duration or without adequate indications; Benadryl used inappropriately. | SS=D |
| Failed to post daily nurse staffing data including census and hours worked for nursing staff. | SS=C |
| Failed to serve correct portion size of pureed meat as per menu specifications. | SS=E |
| Failed to maintain appropriate refrigeration temperatures in food storage areas. | SS=F |
| Failed to complete routine laboratory monitoring (basic metabolic panel) every six months for residents on diuretics. | SS=D |
Report Facts
Facility census: 64
Residents on pureed diet: 13
Residents in fine dining with mechanical altered diets: 15
Residents affected by choking risk: 4
Restorative services frequency: 14
Restorative services frequency: 12
Temperature readings: 46
Temperature readings: 42
Temperature readings: 44
Basic Metabolic Panel (BMP) frequency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding pacemaker checks, bowel protocol, medication use, and restorative services. | |
| Activities Director | Observed not conducting scheduled activities and taking lunch break during activity time. | |
| Employee 51 | Social Worker | Interviewed about failure to update resident rights notifications annually. |
| Dietary Manager | Interviewed about portion sizes, food storage temperatures, and meal supervision. |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 11
Apr 12, 2007
Visit Reason
Complaint investigation conducted concurrently with the facility's Federal Medicaid certification survey and State licensure inspection, triggered by complaint reference #2-7059.
Findings
The facility was found deficient in multiple areas including failure to inform residents about surrogate decision makers, inadequate activities programming, incomplete social services documentation, failure to ensure cardiac pacemaker checks and constipation interventions, insufficient restorative nursing services, unsafe dining supervision leading to choking risk, unnecessary drug use, failure to post nurse staffing data, incorrect food portioning, improper food storage temperatures, and failure to complete required laboratory monitoring for residents on diuretics.
Complaint Details
Complaint reference #2-7059 was unsubstantiated with no related deficiencies cited. The investigation was conducted concurrently with the Federal Medicaid certification survey and State licensure inspection.
Severity Breakdown
SS=B: 3
SS=C: 1
SS=D: 5
SS=E: 2
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure residents were informed that a surrogate decision maker would act on their behalf. | SS=B |
| Failed to develop and implement a program of group and individual activities to meet residents' needs. | SS=E |
| Failed to provide medically-related social services including updating resident rights notification and social service progress notes. | SS=B |
| Failed to ensure cardiac pacemaker was checked and interventions to prevent constipation were provided. | SS=D |
| Failed to ensure restorative nursing services were provided as ordered. | SS=D |
| Failed to maintain a safe environment during meal services; resident choked due to lack of supervision. | SS=D |
| Failed to ensure medications were not given in excessive duration or without adequate indications. | SS=D |
| Failed to post daily nurse staffing data including census and hours worked. | SS=C |
| Failed to serve correct portion of meat for residents on pureed diet. | SS=E |
| Failed to maintain appropriate refrigerator temperatures in food storage areas. | SS=F |
| Failed to complete routine laboratory monitoring for residents on diuretic therapy. | SS=D |
Report Facts
Facility census: 64
Residents sampled: 13
Residents on pureed diet: 13
Residents in fine dining with mechanical altered diets: 15
Residents affected by chewing/swallowing problems: 4
Restorative services frequency: 14
Restorative services frequency: 12
Benadryl dose: 25
Walk-in cooler temperature: 46
Walk-in cooler temperature: 42
Reach-in cooler temperature: 44
Basic Metabolic Panel frequency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee 51 | Social Worker | Interviewed regarding failure to update resident rights notification annually. |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding pacemaker checks, bowel protocol, restorative services, medication use, and lab monitoring. |
| Dietary Manager | Dietary Manager | Interviewed regarding food portioning and refrigerator temperatures. |
| Activities Director | Activities Director | Observed not conducting scheduled activities. |
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 26, 2007
Visit Reason
The visit was a paper revisit to review corrections following a prior inspection.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, but no detailed findings or severity levels are provided.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay. | Level C |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Jan 4, 2007
Visit Reason
The inspection was conducted in response to a complaint (#2-6329) alleging mistreatment of a resident by staff and concerns about resident rights and social services.
Findings
The facility failed to thoroughly investigate an allegation of abuse by a nursing assistant, did not prevent further potential abuse during the investigation, and failed to report the incident immediately. Additionally, the facility did not provide adequate social services or develop a comprehensive care plan addressing the psychosocial needs of the resident involved in the complaint.
Complaint Details
Complaint #2-6329 involved allegations by Resident #5 of rough treatment by a nursing assistant during a shower in August 2006 and refusal to pull back a privacy curtain in January 2007. The complaint was found to be unsubstantial but revealed unrelated deficiencies.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to investigate and report allegations of abuse and mistreatment of Resident #5 by Nursing Assistant A. | SS=D |
| Failure to provide medically-related social services to Resident #5 to address mental and psychosocial well-being. | SS=D |
| Failure to develop a comprehensive care plan addressing Resident #5's psychosocial needs including anxiety, depression, and fear. | SS=D |
Report Facts
Facility census: 59
Resident sample size: 7
Resident sample size: 8
Dates: Aug 16, 2006
Dates: Aug 28, 2006
Dates: Oct 7, 2006
Dates: Oct 17, 2006
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant A | Nursing Assistant | Named in allegation of rough treatment of Resident #5 |
| Director of Nurses | Director of Nursing (DON) | Facility abuse prevention coordinator; failed to properly investigate abuse allegation |
| Nursing Assistant B | Nursing Assistant | Witness to alleged abuse incident but not interviewed |
| Nursing Assistant C | Nursing Assistant | Reported Resident #5 was upset about the incident |
| Registered Nurse D | Registered Nurse | Received complaint about privacy curtain but did not initiate investigation |
| Social Worker | Social Worker | Did not address psychosocial needs of Resident #5 or provide behavioral counseling |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 12
Feb 17, 2006
Visit Reason
Annual inspection of Belmont Healthcare Center to assess compliance with federal regulations including resident rights, protection of resident funds, staff treatment of residents, dignity, accommodation of needs, environment, resident assessment, care planning, accident prevention, food service, and sanitary conditions.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly statements of resident funds, inadequate investigation and reporting of abuse allegations, failure to maintain resident dignity during meals and activities, lack of accommodation for indoor smoking for long-term residents, unpleasant odors and unsanitary conditions in resident rooms, excessive noise at night, incomplete resident assessments by unlicensed staff, unclear medication orders, unsecured bed side rail pads, faulty bed wheel locks causing resident injury, failure to serve food in appropriate form, and improper food storage conditions.
Severity Breakdown
E: 6
F: 3
G: 2
D: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility did not distribute quarterly written statements of resident funds to residents or legal representatives as required. | E |
| Facility failed to immediately report and thoroughly investigate allegations of abuse and injuries of unknown source involving multiple residents. | E |
| Facility did not promote resident dignity; meal service environment was not conducive to fine dining and residents were observed with unkempt hair and inappropriate lap buddy use during meals. | E |
| Facility failed to provide an indoor smoking area for long-term residents allowed by local ordinance, forcing them to smoke outside in inclement weather. | E |
| Unpleasant odors noted in resident hall and resident equipment was not cleaned or sanitized properly in observed rooms. | E |
| Facility did not maintain comfortable sound levels at night; residents reported excessive noise from laundry carts and floor buffing. | E |
| Resident assessments were conducted and care plans developed by a licensed practical nurse, which is outside the scope of practice for LPNs. | F |
| Medication orders lacked clear indications, dosage instructions, and parameters for PRN medications. | F |
| Side rail pads were not securely attached to beds for multiple residents. | G |
| Resident bed wheels had faulty locks causing a bed to roll out from under a resident resulting in injury; multiple beds had similar faulty locks. | G |
| Food was not served in a form to meet resident needs; a resident was served chicken on the bone despite diet orders to cut meat. | D |
| Food storage conditions were unsanitary; refrigerator temperature was above safe levels and dented cans were found on shelves. | F |
Report Facts
Facility census: 64
Residents with mishandled personal funds statements: 25
Residents with faulty bed wheel locks: 29
Residents with unsecured side rail pads: 4
Residents attending group complaining of noise: 13
Beds moving easily when pushed: 29
Sutures required for resident injury: 16
Inspection Report
Life Safety
Deficiencies: 0
Feb 16, 2006
Visit Reason
The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 6, 2005
Visit Reason
This document is a plan of correction related to a prior inspection, specifically a paper revisit to address previously identified deficiencies.
Findings
The document references a deficiency related to informing residents of their rights and facility rules, including Medicaid-related notifications, but does not provide detailed findings beyond this.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents both orally and in writing of their rights, rules, and services including Medicaid-related notifications. | Level C |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 21, 2005
Visit Reason
This document is a plan of correction related to a previously identified deficiency regarding the facility's obligation to inform residents of their rights, rules, services, and charges.
Findings
The facility was cited for failing to properly inform residents both orally and in writing about their rights, rules, services, and charges as required by regulation.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | SS=C |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 31, 2005
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-5215, to review allegations related to staff treatment of residents and possible neglect.
Findings
The complaint was found to be unsubstantiated with unrelated deficiencies cited. The facility failed to report a possible allegation of neglect involving an employee to the state agency, although an allegation of abuse was reported. The director of nursing viewed the incident as a staff-to-staff conflict rather than resident neglect.
Complaint Details
Complaint reference #2-5215 was unsubstantiated with unrelated deficiencies cited. The facility reported an allegation of abuse on 08/19/05 but did not report an occurrence of resident neglect found during investigation. The director of nursing considered the incident a staff-to-staff conflict rather than neglect.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report to the state agency a possible allegation of neglect involving an employee. | SS=D |
Report Facts
Complaint reference number: 25215
Dates: Aug 31, 2005
Dates: Aug 19, 2005
Dates: Aug 4, 2005
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Aug 10, 2005
Visit Reason
The inspection was conducted as a complaint investigation referencing complaint numbers #2-5108, #2-5163, and #2-5180.
Findings
The facility failed to ensure that the registration status of one of thirteen employees was in good standing at the time of hire. Specifically, an employee was rehired without verification of certification status, despite prior placement on the Nurse Aide Abuse Registry for neglect. The facility did not follow its policy to verify licensure and registration status before hiring.
Complaint Details
Complaint references #2-5108, #2-5163, and #2-5180 were substantiated with deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the registration status of one employee was in good standing at the time of hire. | SS=D |
Report Facts
Facility census: 59
Number of employees reviewed: 13
Employee rehired without verification: 1
Inspection Report
Plan of Correction
Deficiencies: 1
May 1, 2005
Visit Reason
Paper revisit to review the facility's plan of correction following previous deficiencies.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on the facility's obligation to inform residents of their rights and services. No new inspection findings are detailed beyond the plan of correction context.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights and services as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Inspection Report
Routine
Census: 62
Deficiencies: 5
Mar 24, 2005
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, protection of resident funds, mail delivery, resident assessment, pharmacy services, and clinical record documentation.
Findings
The facility was found deficient in multiple areas including failure to have a properly approved surety bond for resident funds, failure to deliver mail on Saturdays, failure to identify and assess a significant change in a resident's condition timely, inaccurate medication labeling, and incomplete nursing documentation following a resident's significant change in condition.
Severity Breakdown
SS=B: 1
SS=C: 1
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility did not have a surety bond properly approved by the WV State Attorney General's Office to protect resident funds. | SS=B |
| Facility failed to ensure delivery of mail to residents on Saturdays. | SS=C |
| Facility failed to identify a significant change in condition and complete a comprehensive assessment within 14 days for Resident #54. | SS=D |
| Medication labeling was inaccurate for Resident #62; medication card labeled 30 mg but order was for 15 mg. | SS=D |
| Facility failed to maintain complete and accurate nursing documentation for Resident #54 after significant change in condition. | SS=D |
Report Facts
Facility census: 62
Residents with personal funds managed: 25
Medications observed: 24
Sampled residents: 13
Nursing notes missing days: 7
Nursing notes missing days: 6
Inspection Report
Life Safety
Deficiencies: 0
Mar 23, 2005
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.
Findings
Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 29, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4146.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-4146 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Mar 2, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4070, substantiated with deficiencies cited.
Findings
The facility failed to provide adequate access to a telephone for twelve of eighteen residents interviewed, with staff unable to locate phones for incoming calls, causing delays in residents receiving calls.
Complaint Details
Complaint reference #2-4070 was substantiated with deficiencies cited related to inadequate telephone access for residents.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide adequate access to a telephone for twelve of eighteen residents. | SS=B |
Report Facts
Residents interviewed: 18
Family/visitors interviewed: 4
Residents lacking adequate telephone access: 12
Facility census: 59
Telephones available: 2
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 5
Jan 15, 2004
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, quality of care, medication administration, infection control, and staff treatment of residents.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate and report incidents of unknown origin, inadequate supervision and assistive devices to prevent falls and elopement, medication administration errors, and improper infection control practices related to Foley catheter care.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate and report one of two incidents of unknown origin involving a resident's injury. | SS=D |
| Failure to provide adequate supervision and assistive devices to prevent falls and elopement for multiple residents. | SS=D |
| Medication administration errors where medications were not given with food as ordered, risking stomach irritation. | SS=D |
| Failure to secure Foley catheter tubing to prevent it from dragging on the floor, risking infection. | SS=D |
| Failure to ensure facility staff do not have a history of abuse, neglect, or mistreatment and failure to report such incidents as required. | SS=D |
Report Facts
Facility census: 62
Falls: 20
Falls: 23
Medication errors: 3
Medications administered: 40
Residents sampled: 13
Inspection Report
Routine
Census: 62
Deficiencies: 2
Jan 15, 2004
Visit Reason
The inspection was conducted as a routine survey to assess compliance with NFPA 101 Life Safety Code standards, including fire drills and fire alarm system maintenance.
Findings
The facility failed to conduct fire drills that included all required basic responses such as simulated fire emergency, occupant removal, and use of a coded phrase. Additionally, the facility did not maintain adequate documentation of fire alarm inspections.
Severity Breakdown
SS=C: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Fire drills did not include a simulated fire emergency, removal of occupants, or use of a coded phrase. | SS=C |
| Facility does not maintain documentation itemizing the results of fire alarm inspections. | SS=C |
Report Facts
Facility census: 62
Fire alarm inspections missing documentation: 2
Inspection Report
Follow-Up
Deficiencies: 0
Feb 28, 2003
Visit Reason
The visit was a follow-up survey conducted to verify correction of previous deficiencies.
Findings
The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements. Specific deficiencies are not detailed in this page.
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 29, 2003
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with federal regulations regarding resident rights, quality of care, and dietary services at Belmont Healthcare Center.
Findings
The facility was found deficient in ensuring resident rights notifications, maintaining proper functioning of mobility monitors to prevent falls for multiple residents, and providing palatable food as two residents complained about the hardness of fried potatoes served.
Severity Breakdown
C: 1
D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and services in writing and orally in a language they understand. | C |
| Failure to ensure mobility monitors were properly applied and functioning for residents #35, #41, and #43 to prevent falls. | D |
| Failure to provide palatable food; two residents (#1 and #18) complained that fried potatoes were too hard to eat. | D |
Report Facts
Residents with non-functioning alarms: 3
Residents with food complaints: 2
Sample size for alarm check: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Informed and secured the mobility monitor alarms for residents #35, #41, and #43. |
Inspection Report
Life Safety
Deficiencies: 0
Jan 15, 2003
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 1981.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 1981.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 6
Dec 18, 2002
Visit Reason
The inspection was conducted based on a complaint investigation regarding verbal abuse by a certified nursing assistant and other quality of care concerns including medication cart security, resident supervision during smoking, dietary service issues, and pharmacy services.
Findings
The facility was found to have multiple deficiencies including failure to protect residents from verbal abuse, failure to secure medication carts during administration, inadequate supervision of residents while smoking placing them at immediate jeopardy, failure to provide properly prepared and palatable food, failure to offer substitutes for refused food, and failure to ensure timely monthly drug regimen reviews by a pharmacist.
Complaint Details
The complaint investigation was triggered by an allegation of verbal abuse by a certified nursing assistant towards Resident #17, which was substantiated. The facility failed to protect residents during the investigation by allowing the CNA to continue direct care. Additional complaints and findings included medication cart security, resident supervision during smoking, dietary service quality, and pharmacy service deficiencies.
Severity Breakdown
SS=D: 3
SS=J: 1
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to protect residents from verbal abuse by a certified nursing assistant who was allowed to continue caring for residents during investigation. | SS=D |
| Failure to secure medication cart during medication administration in resident rooms, preventing direct supervision. | — |
| Failure to adequately supervise incapacitated residents while smoking, placing residents and the facility at immediate jeopardy due to fire risk. | SS=J |
| Failure to provide food prepared by methods that conserve nutritive value, flavor, and appearance; food served was partially cooked and unpalatable. | SS=D |
| Failure to provide substitutes of similar nutritive value when food items were refused by residents. | SS=D |
| Failure to ensure drug regimen of residents was reviewed at least once a month by a licensed pharmacist, resulting in delayed reviews for multiple residents. | SS=F |
Report Facts
Census: 61
Deficiencies cited: 6
Residents with delayed drug regimen review: 11
Residents complaining about food: 7
Residents observed smoking unsupervised: 2
Medications prepared for Resident #52: 14
Inspection Report
Life Safety
Deficiencies: 0
Feb 28, 2002
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 1981.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.
Inspection Report
Follow-Up
Census: 66
Deficiencies: 8
Jan 31, 2002
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies related to resident care, staff treatment, quality of life, quality of care, safety, medication administration, dietary services, infection control, and compliance with advance directives requirements.
Findings
The facility was found deficient in multiple areas including staff mistreatment and neglect of residents, failure to provide scheduled showers and restorative services, unsafe resident environment hazards, improper medication documentation, poor food quality and temperature control, and inadequate infection control practices during ice passes. Several residents reported verbal abuse and neglect, and observations confirmed unsafe practices and poor care standards.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure two residents were free from neglect and verbal abuse by staff. | SS=D |
| Failure to promote care that maintains or enhances resident dignity during meal times. | SS=D |
| Failure to provide scheduled showers to six residents unable to bathe themselves. | SS=E |
| Failure to provide range of motion and restorative services per physician's orders for five residents. | SS=E |
| Failure to ensure resident environment was free of accident hazards, including unpadded bedrails and slip hazards in dining area. | SS=D |
| Failure to document behaviors to justify antipsychotic drug use for one resident. | SS=D |
| Failure to serve food that was palatable, at proper temperatures, and prepared to maintain nutritive value. | SS=F |
| Failure to follow infection control policy during ice pass, contaminating ice with scoop. | SS=D |
Report Facts
Resident census: 66
Sampled residents: 15
Residents with missed showers: 6
Residents with missed restorative services: 5
Staff suspensions: 1
Food temperature: 113
Food temperature: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed care plan and MDS findings; confirmed CNA suspension |
Inspection Report
Annual Inspection
Capacity: 66
Deficiencies: 7
Jan 28, 2002
Visit Reason
The inspection was conducted as a standard annual survey of Belmont Healthcare Center to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including quality of life, quality of care, accident hazard prevention, use of antipsychotic drugs, and dietary services. Specific issues included failure to provide scheduled showers and range of motion treatments, unsafe bedrails, inadequate documentation for antipsychotic drug use, and serving food at improper temperatures and with poor flavor.
Severity Breakdown
E: 4
D: 2
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Residents #29 and #52 were seated in the dining room for an extended period before being served lunch. | E |
| Resident #15 did not receive scheduled showers twice per week as required. | E |
| Four residents (#23, #47, #56, #57) did not receive scheduled showers to maintain personal hygiene. | E |
| Five residents (#15, #32, #47, #56, #57) did not receive prescribed range of motion and restorative services. | E |
| Resident #56 was found with head stuck in bedrails; rails were not padded as required, creating an accident hazard. | D |
| Resident #47's use of antipsychotic drug Risperdal was not supported by consistent behavioral documentation. | D |
| Food served was not palatable, was at improper temperatures, and was sometimes overcooked or undercooked, affecting all residents on oral diet. | F |
Report Facts
Facility total capacity: 66
Residents sampled: 15
Residents not receiving scheduled showers: 4
Residents not receiving prescribed range of motion services: 5
Food temperature measured: 113
Food temperature measured: 110
Food temperature measured: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed shower schedule and resident concerns about shower frequency | |
| Certified Nursing Assistant (CNA) | Assisted resident #56 when found with head stuck in bedrail |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 8
Sep 19, 2001
Visit Reason
Complaint #2-1215 investigation regarding failure to provide care that promotes residents' dignity and respect, and other quality of care and documentation issues.
Findings
The facility failed to provide care that promotes dignity and respect for three residents, failed to ensure accurate resident assessments and care plans, did not implement physician orders for catheterization, failed to provide necessary nutrition and oral hygiene care, and did not properly document wound assessments and clinical records for multiple residents.
Complaint Details
Complaint #2-1215 related to failure to provide care that promotes dignity and respect, and other quality of care issues.
Severity Breakdown
SS=D: 6
SS=E: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide care that promotes dignity and respect, including staff entering resident rooms without knocking or asking permission. | SS=D |
| Failure to ensure resident assessment instruments were signed by a registered nurse certifying completion. | SS=D |
| Failure to develop a comprehensive care plan with measurable objectives and timetables for a resident with positioning problems. | SS=D |
| Failure to periodically review and revise a resident's care plan after assessment. | SS=D |
| Failure to implement physician's orders for catheterization when resident unable to void. | SS=D |
| Failure to provide necessary care and services to maintain good nutrition and oral hygiene for a resident. | SS=D |
| Failure to document weekly wound assessments for residents with pressure ulcers, including size, stage, exudate, and healing progression. | SS=E |
| Failure to maintain complete and accurate clinical records for nine residents, including documentation errors related to wound care, catheter care, turning and positioning, oral care, medication orders, and restraint documentation. | SS=F |
Report Facts
Census: 64
Residents reviewed: 12
Residents with deficient clinical records: 9
Pressure ulcer assessment missing weeks: 2
Pressure ulcer assessment missing weeks: 3
Inspection Report
Routine
Census: 62
Deficiencies: 11
Mar 1, 2001
Visit Reason
Routine inspection of Belmont Healthcare Center to assess compliance with federal regulations regarding resident rights, quality of care, environment, dietary services, infection control, and clinical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to properly assess and reduce physical restraints, inadequate response to resident call lights, unsafe maintenance of assistive devices, medication administration errors, unsecured medication carts, inadequate supervision to prevent resident falls, improper food handling and serving temperatures, failure to provide special eating utensils, and incomplete clinical records.
Severity Breakdown
SS=A: 1
SS=C: 3
SS=D: 5
SS=E: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to engage in a systematic and gradual process toward reducing physical restraints for Resident #61. | SS=D |
| Failure to ensure residents' right to reasonable accommodations and timely response to call lights for Residents #50, #28, #16, and #14. | SS=E |
| Failure to provide maintenance services to assistive devices, including damaged lap buddy and wheelchair brake handle for Residents #50, #24, and #27. | SS=D |
| Failure to administer medication according to individual plan of care for Resident #13, including late medication administration. | SS=D |
| Failure to ensure medication carts were locked and medication drawers closed when unattended, posing hazard to residents. | SS=E |
| Failure to provide adequate supervision and assistance to prevent accidents for Residents #61, #14, #16, and #50, resulting in multiple falls and injuries. | SS=E |
| Failure to serve microwaved food at proper temperature; creamed corn served at 127 degrees. | SS=D |
| Failure to handle linens according to infection control policy, risking cross contamination. | SS=C |
| Failure to provide special eating equipment and utensils for Resident #50 as per care plan. | SS=D |
| Failure to store, prepare, distribute, and serve food under sanitary conditions, including improper handling of steam table lids and inadequate hair coverings for cooks. | SS=C |
| Failure to maintain complete and accurately documented clinical records for Resident #63, including missing physician orders for appointments and admissions. | SS=A |
Report Facts
Residents sampled: 13
Resident census: 62
Medication administration delay: 90
Temperature of microwaved food: 127
Residents reporting cold food: 5
Residents in group interview: 8
Inspection Report
Life Safety
Deficiencies: 2
Mar 1, 2001
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically regarding corridor doors and exit access doors in the facility.
Findings
The survey found that not all corridor doors were maintained to close without impediment, including a corridor door held open with a rubber door stop. Additionally, two dining room exit doors failed to close properly under the power of self-closing devices due to the door bottoms striking the metal threshold.
Severity Breakdown
SS=A: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Corridor door to the maintenance room was held open with a rubber door stop, preventing proper closure. | SS=A |
| Two dining room exit doors would not close under the power of the self-closing device due to the bottom of the door striking the metal threshold. | SS=C |
Report Facts
Number of dining room exit doors failing to close: 2
Date of survey: Mar 1, 2001
Inspection Report
Life Safety
Deficiencies: 0
Apr 20, 2000
Visit Reason
The inspection was conducted to assess the facility's compliance with the Life Safety Code NFPA 101 - 1981 New.
Findings
Based on observation and review of facility documentation from April 17-20, 2000, the facility was determined to be in compliance with the Life Safety Code NFPA 101 - 1981 New.
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 17, 2000
Visit Reason
The document is a plan of correction related to deficiencies identified during a facility inspection.
Findings
The facility was found not to provide a fully functional environment as 3 of 4 shower stalls in the Central Shower room were out of service due to missing shower hose/head assemblies.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 3 of 4 shower stalls in the Central Shower room were out of service due to missing shower hose/head assemblies. | SS=C |
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