Inspection Reports for Belmont Manor Nursing & Rehabilitation Center
34 Agassiz Ave, Belmont, MA 02478, MA, 02478
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 13
Date: Dec 5, 2024
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident dignity, medication administration, abuse prevention, care planning, respiratory care, nutrition, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care during meals, improper medication self-administration, failure to investigate and report bruises of unknown origin, lack of baseline and dementia care plans for several residents, failure to implement contracture management, inadequate accident prevention measures, failure to maintain residents' nutritional status, improper respiratory care including unclean oxygen concentrator filters and untimely tubing changes, inaccurate medical record documentation, and failure to follow infection control protocols for shared equipment.
Deficiencies (13)
Failure to provide a dignified existence for residents during meals and catheter care.
Failure to ensure Resident #118 did not self-administer medications when assessed as unable.
Failure to investigate and report bruises of unknown origin for Resident #4.
Failure to develop baseline care plans for dementia within 48 hours for multiple residents.
Failure to develop and implement complete care plans with measurable goals for Resident #103.
Failure to review and revise care plan for stage 3 left heel pressure ulcer for Resident #32.
Failure to implement contracture management intervention (palmar guard) as ordered for Resident #32.
Failure to ensure padded side rails were in place for Residents #77 and #57 as ordered.
Failure to maintain acceptable nutritional status and timely interventions for Resident #25 with significant weight loss.
Failure to provide appropriate respiratory care including clean oxygen concentrator filters and timely oxygen tubing changes for Residents #223 and #53.
Failure to accurately document care interventions for Residents #77, #57, #53, and #32.
Failure to develop and implement individualized dementia care plans for multiple residents on the dementia special care unit.
Failure to follow infection control standards for cleaning shared resident equipment.
Report Facts
Deficiencies cited: 13
Resident sample size: 24
Resident #222 sample size: 24
Resident #23 sample size: 24
Resident #118 BIMS score: 13
Resident #222 BIMS score: 15
Resident #23 BIMS score: Severely impaired cognition stated but no numeric score given.
Resident #4 BIMS score: Severe cognitive impairment stated but no numeric score given.
Resident #77 BIMS score: 5
Resident #57 BIMS score: 15
Resident #25 BIMS score: 3
Resident #41 BIMS score: 6
Resident #69 BIMS score: 5
Resident #25 weight loss: 15
Resident #25 weight loss: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Unit Manager #3 | Nurse Unit Manager | Stated staff should not use cell phones in resident care areas and discussed feeding practices. |
| Charge Nurse #1 | Charge Nurse | Discussed catheter bag privacy and medication self-administration assessment. |
| Nurse #2 | Nurse | Observed medication left at bedside and discussed bruises on Resident #4. |
| CNA #1 | Certified Nurse Assistant | Reported bruises on Resident #4 and discussed reporting responsibilities. |
| Director of Nursing | Director of Nursing | Discussed feeding practices, medication administration, bruises reporting, oxygen concentrator maintenance, and padded side rails expectations. |
| Nurse Unit Manager #2 | Nurse Unit Manager | Discussed feeding practices and padded side rails expectations. |
| Nurse #3 | Nurse | Discussed padded side rails and Resident #57 seizure history. |
| Nurse Unit Manager #4 | Nurse Unit Manager | Discussed oxygen concentrator filter cleaning. |
| Maintenance Director | Maintenance Director | Discussed oxygen concentrator filter cleaning and lack of tracking system. |
| Dietitian | Dietitian | Discussed weight loss monitoring and communication issues. |
| MDS Nurse #2 | MDS Nurse | Discussed care plan development responsibilities. |
| Social Worker #1 | Social Worker | Discussed dementia care needs and care plan development. |
| Nurse #6 | Nurse | Discussed palmar guard use and documentation. |
| CNA #4 | Certified Nursing Assistant | Discussed palmar guard awareness. |
Inspection Report
Routine
Deficiencies: 8
Date: Dec 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident care, privacy, infection control, food safety, and other aspects of nursing home operations.
Findings
The facility was found deficient in multiple areas including allowing a resident to self-administer medication without authorization, failure to secure protected health information on medication carts, inadequate assistance with meals for residents, failure to implement pressure ulcer care, lack of trauma-informed care planning, improper medication labeling and storage, food safety violations, and failure to adhere to infection prevention and control practices.
Deficiencies (8)
Allowed Resident #46 to self-administer torsemide without authorization despite being deemed incapable.
Failed to ensure resident Protected Health Information (PHI) was secure on medication administration computers on multiple nursing units.
Failed to provide assistance with meals as needed for Residents #84 and #40.
Failed to implement physician's order for air mattress for Resident #88, resulting in no air entering the mattress.
Failed to develop a trauma-informed care plan for Resident #108 diagnosed with PTSD.
Failed to properly label medication and ensure medications were stored in locked compartments with access limited to authorized users.
Failed to store and prepare food in accordance with professional standards, including failure to wear hair restraints, unlabeled and undated food, staff food stored with resident food, and decomposed food items.
Failed to ensure nursing and housekeeping staff performed hand hygiene appropriately on Station 1 with residents on isolation precautions.
Report Facts
Residents sampled: 25
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Medication carts observed: 4
Medication carts with deficiencies: 2
Food items unlabeled or undated: 15
Isolation rooms on Station 1: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #3 | Interviewed regarding medication left on Resident #46's bedside table | |
| Unit Manager #1 | Interviewed about medication self-administration and bedside medication storage | |
| Director of Nursing | DON | Interviewed about medication administration policies and medication cart security |
| Charge Nurse | Interviewed about medication cart security and hand hygiene expectations | |
| Nurse #2 | Interviewed about medication cart security and unlabeled medication tablets | |
| Unit Manager #2 | Interviewed about treatment cart security and food safety practices | |
| Certified Nurse Aide #3 | CNA | Interviewed about resident care plans and meal assistance |
| Certified Nurse Aide #4 | CNA | Interviewed about supervision of Resident #40 during meals |
| Food Service Director | FSD | Interviewed about food safety and kitchen practices |
| Social Worker #1 | Interviewed about trauma-informed care planning for Resident #108 | |
| Social Worker #2 | Interviewed about trauma-informed care planning for Resident #108 | |
| Housekeeping manager | Interviewed about hand hygiene and glove use on Station 1 | |
| Maintenance Director | Interviewed about air mattress for Resident #88 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 20, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding the facility's failure to provide nursing care and treatment in accordance with professional standards after Resident #1 experienced an unwitnessed fall on 06/09/23. The investigation focused on the lack of timely assessment, documentation, and notification by nursing staff.
Complaint Details
The investigation was triggered by a complaint regarding Resident #1's fall on 06/09/23. The complaint was substantiated as the facility failed to properly assess, document, and notify appropriate parties following the fall, resulting in actual harm to the resident (right elbow fracture).
Findings
The facility failed to ensure Resident #1 was adequately assessed and monitored after an unwitnessed fall on 06/09/23. Nurse #1 found the resident on the floor but did not document the incident, notify the physician or nursing supervisor, or complete required incident and falls investigation reports. Resident #1 was not assessed until approximately 24 hours later when pain was reported, resulting in a diagnosis of a right elbow fracture. The facility lacked documentation supporting compliance with its own policies and procedures related to fall incidents.
Deficiencies (1)
Failure to provide nursing care and treatment in accordance with professional standards after Resident #1's unwitnessed fall, including lack of timely assessment, documentation, and notification.
Report Facts
Residents Affected: 1
Date of fall: Jun 9, 2023
Date of survey completion: Jul 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Found Resident #1 on the floor after fall, failed to assess, document, or notify per policy | |
| Nursing Supervisor #1 | Notified on 06/10/23, assessed Resident #1, initiated neurological checks, notified physician | |
| Unit Manager #1 | Received report from Nurse #1, communicated with Director of Nursing, confirmed lack of documentation | |
| Nurse Practitioner #1 | Ordered x-rays and hospital evaluation after notification on 06/10/23 | |
| Nurse #2 | Administered Tylenol for Resident #1's pain on 06/10/23 | |
| CNA #2 | Certified Nurse Aide | Did not assist Nurse #1 in picking Resident #1 up from the floor due to being busy |
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 5
Date: Nov 30, 2022
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory standards in a nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, improper medication administration practices, inadequate feeding assistance for dependent residents, poor infection control related to CPAP equipment, and unsecured medication storage.
Deficiencies (5)
Failed to ensure a dignified dining experience; residents were left unattended with food out of reach and no feeding assistance provided.
Failed to ensure professional standards of medication administration; medication was left in food and not observed being ingested by the resident.
Failed to provide required feeding assistance to a totally dependent resident; resident was left unassisted for extended periods during meals.
Failed to maintain infection control practices for CPAP equipment; oxygen tubing was not dated or changed weekly and CPAP mask was stored improperly.
Failed to ensure medication was stored securely; unattended medication was found on nursing station counter and medication room was left unlocked.
Report Facts
Residents observed with untouched plates during lunch: 10
Sampled residents: 26
Medication administration time: 8.3
Oxygen flow rate: 2
CPAP setting: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #4 | Mentioned in relation to feeding assistance failures and medication delivery | |
| Director of Nursing | Director of Nursing | Provided statements regarding feeding assistance and meal service timing |
| Nurse #3 | Acknowledged leaving medication in food without observation | |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided statements on medication administration expectations and CPAP cleaning |
| Certified Nursing Assistant | Certified Nursing Assistant | Provided feeding assistance and interviewed regarding resident feeding needs |
| Nurse #2 | Interviewed about responsibility for CPAP oxygen tubing change | |
| Nurse #1 | Acknowledged leaving medication room unlocked |
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