Inspection Reports for
Belvedere Nursing and Rehabilitation Center, LLC
2600 Park Ave., Hot Springs, AR, 71901
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a failure to follow care planned interventions for Resident #2, specifically the improper use of a gait belt during transfers which resulted in injury.
Complaint Details
The complaint investigation substantiated that Resident #2 was transferred without a gait belt by CNA #1, causing a dislocation of the shoulder, proximal humerus fracture, ligamentous injury, and clavicle injury. The CNA self-reported the incident and was terminated. The facility implemented monitoring and training programs following the incident.
Findings
The facility failed to ensure staff followed care plans requiring one staff member to perform transfers with a gait belt for Resident #2, resulting in actual harm including a dislocated shoulder and fractures. Multiple witness statements, resident interviews, and medical records confirmed the injury was caused by improper transfer without a gait belt. The facility initiated corrective actions including staff training, monitoring transfers, and terminating the responsible CNA.
Deficiencies (1)
Failure to ensure staff followed care planned interventions requiring use of a gait belt for transfers, resulting in injury to Resident #2.
Report Facts
Assessment Reference Date: Feb 26, 2025
BIMS score: 11
Transfers monitored per day: 30
Transfers monitored per day: 20
Transfers monitored per day: 10
CNA #1 last clock out time: 1015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in improper transfer causing injury to Resident #2; self-reported incident; terminated |
| LPN #1 | Licensed Practical Nurse | Assessed Resident #2 after injury and notified on-call provider |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans and monitoring; started 01/27/2025 |
| Administrator | Administrator | Informed of incident, called police and family, suspended and terminated CNA #1 |
| Nurse Consultant | Nurse Consultant | Advised on monitoring program and QAPI related to improper transfer |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with healthcare facility standards, including care planning, safety, dietary practices, and infection control.
Findings
The facility was found deficient in developing comprehensive care plans for residents, maintaining secure and safe environments to prevent accidents, ensuring proper food handling and storage, and implementing effective infection prevention and control practices, including hand hygiene.
Deficiencies (4)
Failed to develop and implement a comprehensive person-centered care plan for Resident #111, specifically not identifying medications prescribed.
Failed to ensure central bath and soiled utility rooms on 300 Hall were locked to prevent resident access to hazardous materials and wet floors; mechanical lift was used despite missing safety clips risking resident injury.
Failed to ensure dietary staff washed hands before handling clean equipment or food; ice machine was dirty; cold dairy products were stored above 41°F.
Failed to ensure proper hand hygiene during perineal care for Resident #55, increasing risk of cross contamination and infection spread.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Temperature: 43
Temperature: 45
BIMS score: 3
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | Confirmed medications ordered for Resident #111 and care plan deficiencies | |
| Certified Nursing Assistant (CNA) #3 | Certified Nursing Assistant | Confirmed central bath and soiled utility rooms should be locked |
| Director of Nursing (DON) | Director of Nursing | Provided information on policies, procedures, and expectations regarding locked rooms, mechanical lift use, and infection control |
| Certified Nursing Assistant (CNA) #4 | Certified Nursing Assistant | Observed using mechanical lift with missing clip |
| Certified Nursing Assistant (CNA) #5 | Certified Nursing Assistant | Observed using mechanical lift with missing clip and contacted maintenance |
| Licensed Practical Nurse (LPN) #6 | Licensed Practical Nurse | Stated mechanical lift should not be used if missing clip |
| Assistant Administrator | Assistant Administrator | Provided procedures and manuals related to mechanical lift use |
| Dietary Aide (DA) #7 | Dietary Aide | Observed handling food with contaminated gloves |
| Dietary Aide (DA) #8 | Dietary Aide | Observed handling napkins without washing hands |
| Certified Nursing Assistant (CNA) #2 | Certified Nursing Assistant | Observed improper hand hygiene during perineal care |
| Certified Nursing Assistant (CNA) #3 | Certified Nursing Assistant | Observed improper hand hygiene during perineal care |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Dec 21, 2023
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity with catheter privacy bags, incomplete significant change assessments, inaccurate and outdated care plans, inadequate fall prevention interventions, improper management of thickened liquids, lack of physician orders for oxygen therapy, improper medication storage, ineffective quality assurance processes, and infection control lapses such as improper storage of ice scoops.
Deficiencies (10)
Failed to ensure catheter output bags were concealed in a privacy bag to protect resident dignity for 2 residents with indwelling catheters.
Failed to complete a Significant Change in Status Minimum Data Set (MDS) after decline in ADLs for 1 resident.
Failed to complete comprehensive assessments within regulatory time frames for 2 residents.
Failed to ensure individualized care plans addressed hearing loss for 1 resident.
Failed to update individualized care plans to reflect current resident needs for 2 residents.
Failed to implement fall prevention interventions resulting in multiple falls and fractures for 1 resident; failed to ensure correct thickened liquid consistency for 2 residents.
Failed to ensure physician order was in place prior to oxygen administration for 1 resident; failed to store oxygen tubing and nebulizer mouthpieces in a sanitary manner for 2 residents.
Failed to ensure medications were not left in a resident's room for 1 resident.
Failed to develop and implement effective Quality Assurance and Performance Improvement (QAPI) plans to prevent repeated deficiencies related to care plans.
Failed to store ice scoop in a closed container to prevent contamination and ensure infection control.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 119
Residents at risk for falls: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Certified Nursing Assistant | Interviewed about catheter bag privacy |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed about oxygen therapy orders and tubing storage |
| Director of Nursing | Director of Nursing | Interviewed about catheter bag privacy, oxygen therapy, fall prevention, and medication storage |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided policies and interviewed about QAPI and infection control |
| MDS Coordinator | MDS Coordinator | Interviewed about MDS assessments and care plan accuracy |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed about fall prevention interventions and thickened liquids |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed about thickened liquids |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed about communication with resident with hearing loss and medication storage |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
Date: Oct 13, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to develop and implement a water management program to prevent waterborne illnesses caused by Legionella, following positive Legionella test results in residents.
Complaint Details
The visit was complaint-related due to positive Legionella tests in two residents and multiple respiratory infections. The facility was found to have inadequate water management and infection control practices related to Legionella. The immediate jeopardy status was declared due to risk to all 114 residents.
Findings
The facility failed to implement an adequate water management program, resulting in immediate jeopardy to resident health due to Legionella infections in multiple residents. The facility had incomplete water management documentation, inadequate monitoring, and delayed response to positive Legionella tests, but took corrective actions including raising water heater temperatures and scheduling super chlorination.
Deficiencies (1)
Failure to develop and implement a water management program to prevent waterborne illnesses caused by Legionella.
Report Facts
Residents affected: 114
Respiratory infections: 10
Legionella test result: 2272.6
Water temperature range: 106
Water temperature range: 112
Water temperature range: 105
Water temperature range: 109
Chlorine level detected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist #1 | Infection Preventionist | Interviewed regarding Legionella testing and infection control measures |
| Maintenance Director | Maintenance Director | Provided water temperature logs, described water management practices, and responded to surveyor questions about water system |
| Administrator | Administrator | Confirmed use of water management program document, provided census data, and discussed corrective actions |
| Infection Preventionist #2 | Infection Preventionist | Interviewed about symptom onset and water management team meetings |
Inspection Report
Routine
Deficiencies: 8
Date: Sep 28, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, treatment, and safety, including wound care, care planning, medication administration, oxygen therapy, food preparation, and infection control.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments related to wounds, incomplete care plans for residents with pressure ulcers and oxygen therapy, failure to obtain physician orders for wound care, improper administration of medications via PEG tube, incorrect oxygen flow rates, unsecured medication and treatment carts, improperly prepared pureed food, and inadequate food safety and hygiene practices.
Deficiencies (8)
Failed to ensure Quarterly Minimum Data Set (MDS) assessment accurately reflected wounds for Resident #37.
Failed to develop and implement a complete care plan addressing pressure ulcers and oxygen therapy for Residents #36, #37, and #40.
Failed to notify physician and obtain orders for wound care for Resident #34 after an incident causing a wound.
Failed to ensure Licensed Practical Nurse checked for PEG tube placement according to standard nursing practice before administering medications for Resident #229.
Failed to ensure oxygen was administered at the flow rate ordered by the physician for Residents #44 and #72.
Medication and treatment carts were left unattended and unlocked, risking unauthorized access to medications and supplies.
Pureed food items served were not blended to a smooth, lump-free consistency for residents requiring pureed diets.
Failed to maintain ice machines and scoop holders in clean condition; staff failed to wash hands before handling clean equipment; food storage and labeling deficiencies were noted.
Report Facts
Residents affected: 8
Residents affected: 24
Total census: 80
Medication carts observed unlocked: 3
Treatment carts observed unlocked: 1
Pureed diet residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered medications via PEG tube without proper placement verification |
| LPN #2 | Licensed Practical Nurse | Left medication cart unlocked and unattended |
| LPN #3 | Licensed Practical Nurse | Left medication cart unlocked and unattended in dining room |
| LPN #4 | Licensed Practical Nurse | Left medication cart unlocked and unattended in hallway |
| LPN #5 | Licensed Practical Nurse | Observed oxygen flow rate discrepancies and discussed responsibility for oxygen management |
| Treatment Nurse | Responsible for treatment cart keys and wound care orders; admitted to leaving keys on cart | |
| Director of Nursing | Director of Nursing | Provided policy information and acknowledged deficiencies in oxygen therapy and medication cart security |
| Administrator | Administrator | Provided information on policies and acknowledged lack of specific medication cart safety policy |
| Dietary Employee #1 | Dietary Employee | Handled clean plates and napkins without handwashing |
| Dietary Employee #2 | Dietary Employee | Handled clean plates without handwashing |
| Dietary Employee #3 | Dietary Employee | Contaminated gloves by touching counter and then handled food |
| Dietary Employee #4 | Dietary Employee | Contaminated gloves by touching recipe book and then handled blender blade |
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