Inspection Reports for Belmont Terrace Nursing and Rehabilitation Center
7300 WOODSPOINT DRIVE, FLORENCE, KY, 41042
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
14.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
213% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
114 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 24, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse and neglect involving residents, and failure to provide timely notification of discharge and transfer for a resident.
Complaint Details
The complaint investigation substantiated abuse and neglect involving residents R36, R40, and R169, including a staff member unplugging a call light device and a resident-to-resident physical altercation causing injury. The investigation also found failure to notify the State Guardian and Ombudsman in writing of the discharge of resident R219, and failure to provide a 30-day notice of transfer/discharge, resulting in legal action and a stay of discharge.
Findings
The facility failed to keep residents free from abuse and neglect for 3 of 11 sampled residents, including incidents involving call light tampering and resident-to-resident altercations. Additionally, the facility failed to notify the State Guardian and Ombudsman in writing of its intentions to discharge a resident and the reasons for discharge, violating resident rights.
Deficiencies (2)
Failure to protect residents from abuse and neglect, including tampering with a call light device and resident-to-resident physical altercation.
Failure to provide timely notification to the resident's representative and Ombudsman before transfer or discharge, including appeal rights.
Report Facts
Residents sampled: 11
Residents affected: 3
Residents sampled for discharge notification: 27
Residents affected: 1
Damage caused by resident R219: 10000
BIMS score: 3
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA8 | State Registered Nurse Aide | Admitted to removing call light device; placed on leave pending investigation |
| SRNA9 | State Registered Nurse Aide | Day shift SRNA who reconnected call light device and reported allegation |
| Director of Nursing | Director of Nursing | Provided statements on abuse prevention and notification procedures |
| Administrator | Facility Administrator | Interviewed regarding abuse allegations and discharge procedures |
| Discharge Planner | Discharge Planner at Behavioral Health Facility | Notified State Guardian and attempted communication with facility regarding resident R219 |
| Business Office Manager | Business Office Manager | Described discharge notification process and mailing procedures |
| Legal Counsel | Legal Counsel for Resident R219 | Represented resident in discharge appeal and stay of discharge |
| Guardian | State Guardian for Resident R219 | Reported lack of discharge notice and communication failures |
| District LTC Ombudsman | District Long-Term Care Ombudsman | Reported lack of notification of discharge and facility communication issues |
| Regional President | Regional President | Provided statements on resident care and discharge reasons |
| Medical Director | Medical Director | Provided statements on psychiatric services and discharge planning |
Inspection Report
Routine
Census: 114
Deficiencies: 2
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control policies, and immunization procedures, including the management of catheter care and vaccination documentation for residents.
Findings
The facility failed to implement effective infection prevention and control practices, including improper catheter bag management and unsanitary storage of resident supplies, potentially affecting all 114 residents. Additionally, the facility failed to provide or document appropriate pneumococcal immunizations and education for 5 of 6 sampled residents.
Deficiencies (2)
Failure to implement infection prevention and control program, including catheter bag management and sanitary storage of supplies.
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations, including documentation of vaccine education and refusals.
Report Facts
Residents affected: 114
Sampled residents: 27
Sampled residents: 6
Boxes stored on floor: 13
Boxes visible: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 2 | Stated catheter bags needed to be secured to prevent dragging on floor and reduce infection risk | |
| Director of Nursing (DON) | Explained catheter bag care expectations and lack of facility policy for catheter bags | |
| State Registered Nurse Aide/Central Supply Manager (SRNA/CSM) 5 | Reported unsanitary storage of supplies and requested additional storage space | |
| Infection Preventionist (IP) | Expressed concerns about infection risk from supplies stored on floor and emphasized importance of following CDC recommendations | |
| Regional Nurse Consultant (RNC) | Noted lack of surveillance data and destruction of infection prevention records by former IP | |
| Administrator | Stated expectations for policy adherence and responsibility of IP for infection prevention oversight | |
| Medical Director | Emphasized importance of following IPCP and ensuring residents receive vaccines |
Inspection Report
Routine
Census: 129
Deficiencies: 20
Date: Mar 8, 2024
Visit Reason
Routine inspection of Belmont Terrace Nursing and Rehabilitation Center to assess compliance with regulatory requirements including resident rights, care planning, infection control, staffing, and safety.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy during catheter care, incomplete care planning and implementation, inadequate staff training and competencies, insufficient staffing levels, medication errors, infection control lapses, nutritional deficiencies, inadequate activity programs, and ineffective quality assurance processes.
Deficiencies (20)
Failure to ensure resident dignity and privacy during catheter care, including failure to use privacy curtains and dignity bags.
Failure to involve resident or representative in care planning process.
Failure to reasonably accommodate resident needs and preferences including wheelchair repair, language services, call light accessibility, shopping assistance, and hearing aid batteries.
Failure to ensure residents' rights to request, refuse, or discontinue treatment and to formulate advance directives.
Failure to maintain a safe, clean, comfortable, and homelike environment including strong odors, dirty linens, loose metal plates creating tripping hazards, and improper storage of clean and dirty items.
Failure to protect residents from abuse and neglect including resident-to-resident altercations, verbal abuse by staff, and neglect in care.
Failure to protect residents from misappropriation of property by other residents and failure to prevent medication errors.
Failure to protect residents from involuntary seclusion by improperly closing doors on residents unable to open them.
Failure to provide accurate assessments including dental care and oxygen use.
Failure to provide care and assistance to perform activities of daily living including grooming, hygiene, and dressing.
Failure to provide activities to meet individual resident needs and preferences.
Failure to provide appropriate treatment and care according to orders including wound care, catheter care, and tube feeding care.
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents including inaccurate elopement binders, inadequate supervision, and ineffective alarm system.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Failure to ensure medication error rates are less than 5 percent, including administration of medications to wrong residents.
Failure to provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards.
Failure to provide and implement an infection prevention and control program including proper hand hygiene, disinfection of shared equipment, catheter care, and resident dignity during care.
Failure to implement a program that monitors antibiotic use including monitoring and assessment of antibiotic therapy for residents.
Failure to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff, and properly document vaccination status.
Report Facts
Medication errors: 8
Nurse aide staffing hours: 200
Nurse aide staffing hours: 230
Weight loss: 22
Medication errors: 6
Medication errors: 9
Medication errors: 30
Medication errors: 26.67
Residents on wander guard: 21
Resident census: 129
Resident census: 150
Residents on 100 unit: 38
Nurse aide staffing hours: 154.5
Residents on 300 hall: 54
Residents per aide: 20
Shower frequency: 2
BIMS score: 14
BIMS score: 13
BIMS score: 6
BIMS score: 14
BIMS score: 14
BIMS score: 7
BIMS score: 15
BIMS score: 15
BIMS score: 12
BIMS score: 15
BIMS score: 15
BIMS score: 14
BIMS score: 15
BIMS score: 3
BIMS score: 15
BIMS score: 15
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #20 | State Registered Nurse Aide | Named in catheter care and dignity bag findings |
| LPN #7 | Licensed Practical Nurse | Named in catheter care and dignity bag findings |
| DON #1 | Director of Nursing | Named in catheter care, dignity, and care plan findings |
| DON #2 | Director of Nursing | Named in catheter care, dignity, and care plan findings |
| Administrator | Named in catheter care, dignity, care plan, staffing, infection control, and other findings | |
| SRNA #7 | State Registered Nurse Aide | Named in sexual behavior and abuse findings |
| LPN #16 | Licensed Practical Nurse | Named in abuse and staffing findings |
| Housekeeper #3 | Named in abuse findings | |
| LPN #6 | Licensed Practical Nurse | Named in medication error findings |
| DON/IP #1 | Director of Nursing/Infection Preventionist | Named in infection control and antibiotic stewardship findings |
| SRNA #12/KMA #1 | State Registered Nurse Aide/Kentucky Medication Aide | Named in infection control findings |
| LPN #1 | Licensed Practical Nurse | Named in catheter care and care plan findings |
| SRNA #5 | State Registered Nurse Aide | Named in catheter care and infection control findings |
| SRNA #23 | State Registered Nurse Aide | Named in catheter care and staffing findings |
| SRNA #18 | State Registered Nurse Aide/Kentucky Medication Aide | Named in infection control findings |
| LPN #4 | Licensed Practical Nurse | Named in wound care findings |
| RN #4 | Registered Nurse/Wound Care Nurse | Named in wound care findings |
| LPN #14 | Licensed Practical Nurse | Named in catheter care findings |
| SRNA #40 | State Registered Nurse Aide | Named in infection control and dignity findings |
| SRNA #15 | State Registered Nurse Aide | Named in infection control findings |
| LPN #28 | Licensed Practical Nurse | Named in infection control findings |
| LPN #2 | Licensed Practical Nurse | Named in infection control findings |
| SRNA #19 | State Registered Nurse Aide | Named in infection control findings |
| SRNA #3 | State Registered Nurse Aide | Named in catheter care and infection control findings |
| SRNA #26 | State Registered Nurse Aide | Named in seclusion findings |
| LPN #9 | Licensed Practical Nurse | Named in seclusion findings |
| SRNA #41 | State Registered Nurse Aide | Named in elopement findings |
| LPN #8 | Licensed Practical Nurse | Named in staffing findings |
| SRNA #24 | State Registered Nurse Aide | Named in staffing findings |
| LPN #16 | Licensed Practical Nurse | Named in staffing findings |
| SRNA #10 | State Registered Nurse Aide | Named in staffing findings |
| RN #3 | Registered Nurse | Named in activities findings |
| AD | Activities Director | Named in activities findings |
| IDON | Interim Director of Nursing | Named in activities and nutrition findings |
| IDM | Interim Dietary Manager | Named in nutrition findings |
| RD | Registered Dietician | Named in nutrition findings |
Inspection Report
Routine
Deficiencies: 8
Date: Feb 26, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, abuse prevention, care planning, staffing, nutrition, and environmental conditions.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; failure to protect residents from abuse and neglect including resident-to-resident altercations and misappropriation of property; failure to develop and implement comprehensive care plans addressing residents' needs; failure to provide adequate nursing staff to meet residents' needs; failure to provide appropriate treatment and care according to orders; failure to ensure adequate supervision and accident hazard prevention; and failure to meet residents' nutritional needs as per diet orders.
Deficiencies (8)
Failure to maintain a safe, clean, and homelike environment including strong urine and feces odor, cracked ceiling tiles, dirty air vents and floors, loose and warped metal plate creating tripping hazard, and improper storage of clean and dirty items together.
Failure to protect residents from abuse and neglect including resident-to-resident altercations, verbal abuse by staff, and misappropriation of property by a resident.
Failure to develop and implement comprehensive care plans that meet residents' medical, nursing, mental, and psychosocial needs, including interventions for pressure ulcer prevention, elopement risk, sexual activity consent, catheter care, G-tube site care, and wheelchair safety.
Failure to provide care and assistance to perform activities of daily living for residents unable to do so, resulting in poor grooming, personal, and oral hygiene.
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals, including wound care and tube feeding site care.
Failure to ensure the nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, including failure to maintain accurate elopement binders, provide appropriate supervision to prevent elopements, and maintain an effective alarm system.
Failure to provide enough nursing staff every day to meet the needs of every resident, including nurse aides and licensed nurses on each shift, resulting in insufficient care and delayed responses to call lights.
Failure to ensure menus meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Report Facts
Deficiencies cited: 9
Residents affected: 104
Nurse aide hours required: 230
Nurse aide hours required: 260
Nurse aide hours worked: 200
Residents on 100 Unit: 38
Residents on 300 Hall: 54
Staffing: 3
Staffing: 2
Staffing: 3
Staffing: 1
Staffing: 1
Staffing: 3
Staffing: 1
Staffing: 1
Residents on 100 Unit: 40
Residents on 100 Unit: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in interviews related to care plan implementation, abuse reporting, and medication cart security |
| SRNA #7 | State Registered Nurse Aide | Named in interviews related to resident sexual behavior observation and abuse reporting |
| DON #1 | Director of Nursing | Named in interviews related to care plan expectations, abuse reporting, and staff education |
| Administrator | Named in interviews related to facility management, abuse prevention, and staffing | |
| Maintenance Director | Named in interviews related to alarm system and facility safety | |
| LPN #7 | Licensed Practical Nurse | Named in interviews related to care plan implementation and elopement binder |
| SRNA #24 | State Registered Nurse Aide | Named in interviews related to staffing and resident care |
| RN #4 | Registered Nurse/Wound Care Nurse | Named in interviews and observations related to wound care |
| Dietary Manager | Named in interviews related to nutrition and meal service |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: May 14, 2021
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to notify physicians of significant changes in residents' conditions, pain management issues, resident-to-resident abuse, medication errors, infection control deficiencies, and other quality of care concerns.
Complaint Details
Complaint investigation revealed multiple areas of noncompliance including failure to notify physicians of changes in condition, pain management issues, abuse, medication errors, infection control deficiencies, and care plan deficiencies. Immediate jeopardy was identified and later removed after the facility submitted an acceptable Allegation of Compliance.
Findings
The facility failed to notify physicians of significant changes in condition, failed to provide adequate pain management, failed to protect residents from abuse, failed to ensure proper medication reconciliation and storage, failed to maintain infection control practices, and failed to provide appropriate care plans and skin assessments. Immediate jeopardy was identified related to pain management, pressure ulcer care, respiratory care, and medication reconciliation. The facility provided an acceptable Allegation of Compliance and the immediate jeopardy was removed prior to exit with remaining non-compliance at a scope and severity of D.
Deficiencies (12)
Failure to notify physician of significant change in condition and failure to reorder pain medication after expiration.
Failure to provide a comfortable, homelike environment due to strong urine and fecal odors throughout the facility.
Failure to protect residents from resident-to-resident abuse.
Failure to protect residents from misappropriation of resident property.
Failure to develop and implement comprehensive care plans that meet residents' needs, including pain management and pressure ulcer prevention.
Failure to develop complete care plans within 7 days of assessment and failure to revise care plans to address respiratory status.
Failure to ensure drugs and biologicals were stored in an orderly manner and labeled with expiration dates.
Failure to provide and implement an infection prevention and control program including proper PPE use, hand hygiene, and cleaning of shared equipment.
Failure to provide safe and appropriate respiratory care for a resident when needed, including failure to administer ordered medications and monitor respiratory status.
Failure to provide safe, appropriate pain management for a resident who requires such services, including failure to assess pain and notify physician of changes.
Failure to ensure consultant pharmacist medication regimen review recommendations were received, reviewed, and acted upon timely by providers.
Failure to implement gradual dose reductions and monitor psychotropic medications appropriately.
Report Facts
Residents sampled: 30
Residents with pain issues reassessed: 19
Medication Regimen Reviews performed: 153
Medication Regimen Review recommendations: 80
Medication Regimen Reviews performed: 156
Medication Regimen Review recommendations: 72
Shower sheets documented: 2
Shower sheets documented: 3
Shower sheets documented: 4
Days without documented pain assessment: 9
Days narcotic pain medication ordered: 3
Days PRN psychotropic medication limited to: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #9 | Licensed Practical Nurse | Assigned to Resident #110, involved in pain management and wound care |
| RN #3 | Registered Nurse | Observed Resident #110's change in condition and notified physician |
| ADON | Assistant Director of Nursing | Oversight of nursing staff and pain management policies |
| DON | Director of Nursing | Responsible for nursing staff oversight and care plan compliance |
| Administrator | Administrator | Facility oversight and responsible for addressing odors and medication reconciliation |
| SRNA #11 | State Registered Nurse Aide | Reported Resident #110's pain and care needs |
| Agency LPN #10 | Licensed Practical Nurse | Cared for Resident #110 and aware of pain complaints |
| ARNP | Advanced Practice Registered Nurse | Responsible for reviewing pharmacy recommendations and pain management |
| Pharmacist | Consultant Pharmacist | Performed medication regimen reviews and made recommendations |
| LPN #3 | Licensed Practical Nurse | Discharged Resident #81 and involved in medication reconciliation |
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