Bel-Air Manor Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bel-Air Manor Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Feb 23, 2024

  Based on a review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for change in condition, the facility failed to ensure a resident, who was found unresponsive during the dinner meal, was promptly identified as a choking victim. The facility staff failed to administer the Heimlich maneuver. Upon Emergency Medical Service arrival, two whole grapes were suctioned from Resident #1's airway by EMS staff, the resident was subsequently hospitalized for a choking episode resulting in a finding of Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF805Feb 23, 2024

  Based on a review of the clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for diet consistency, the facility failed to ensure the resident was served the physician ordered diet consistency with a subsequent choking episode resulting in a finding of Immediate Jeopardy. Please cross reference F 684 Resident #1 was admitted with diagnoses that include dysphagia, hemiplegia affecting right side dominant side, aphasia, and cerebral infarction. […]

• Actual harm, patternF760Jul 20, 2026

  Based on review of the clinical record, facility documentation, facility policy, camera footage, and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for pain management, the facility failed to ensure the resident remained free of significant medication errors. This included failure to administer and replace fentanyl patches every 72 hours as ordered, maintain accountability of fentanyl patches as controlled substances, accurately transcribe and implement physician's medication orders, administer oxycodone every four (4) hours as ordered, recognize and correct medication administration errors, and adequately assess and manage Resident #2's pain. […]

• Actual harm, isolatedF697Jul 20, 2026

  Based on clinical record review, facility documentation, facility policies, interviews, and observations, for one (1) of three (3) sampled residents (Resident #2) reviewed for pain management, the facility failed to ensure pain medications were administered according to physician's orders. This included failure to administer and replace fentanyl patches every 72 hours as ordered, maintain accountability of fentanyl patches as controlled substances, accurately transcribe and implement physician's medication orders, administer oxycodone every four (4) hours as ordered, recognize and correct medication administration errors, and adequately assess and manage Resident #2's pain. […]

• No harm, potential for more than minimal, patternF658Jun 2, 2025

  Based on review of clinical records, interviews, and facility documentation for three (3) of three (3) residents (Resident #1, #2, and #3) for medication administration, the facility failed to ensure residents blood glucose levels were obtained before meals and failed to ensure insulin was administered before meals according to provider order. The findings included: 1a. Resident #1 was admitted to the facility in April of 2025 and had diagnoses that included Type 2 diabetes mellitus, dementia, and chronic obstructive pulmonary disease. […]