Belgrade Nursing Home

In the surveyor’s words

From the most serious findings on record at Belgrade Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF838Feb 20, 2025

  Based on record review, and interview the facility failed to conduct and document a comprehensive facility-wide assessment which included all necessary components to provide adequate care and services to the residents in the facility. The deficient practice had the potential to affect all 22 residents in the facility. Findings include: Review of the facility's facility assessment on 2/19/25, showed it did not include the following requirements: 1) No input received or requested from the residents or resident families during the creation of the assessment. 2) No recruitment or retention plan for employees. 3) No contingency plan for staffing that does not evoke the emergency preparedness plan. […]

• No harm, potential for more than minimal, widespreadF880Dec 21, 2023

  Based on observation, interview and record review, the facility failed to complete proper disinfection of multi-use equipment (pulse oximeter) was implemented to prevent the spread of infection for 4 of 4 residents (R3, R24, R27, R29). This had the potential to affect all 30 residents and staff. Findings include: On 12/20/23 at 7:26 a.m., trained medication aide (TMA)-A was observed placing pulse oximeter (blood oxygen level) on R24's finger and did not disinfect equipment following use. Continuous observation initiated. At 7:50 a.m., TMA-A was observed in process of placing un-sanitized equipment on R3's finger prior to surveyor interrupting process. TMA-A stated all shared equipment was cleaned with an alcohol disinfecting wipe between resident use. […]

• No harm, potential for more than minimal, widespreadF727Nov 3, 2022

  Based on interview and document review, the facility failed to ensure registered nurse (RN) coverage for 8 consecutive hours per day, 7 days per week. This had the potential to affect all 28 residents. Findings include On 11/3/22, review of the schedule revealed no RN coverage existed for 8/27/22, 8/28/22, 9/10/22, 9/11/22, 9/24/22, 9/25/22, 10/8/22, 10/9/22, 10/22/22, and 10/23/22. On 11/03/22, at 12:44 p.m. administrator stated facility was occasionally without RN coverage for 8 hours. RN was available on-call during hours lacking RN in the facility. Administrator confirmed no RN coverage existed for 8/27/22, 8/28/22, 9/10/22, 9/11/22, 9/24/22, 9/25/22, 10/8/22, 10/9/22, 10/22/22, and 10/23/22. Further, the facility did not have a staffing waiver. […]

• No harm, potential for more than minimal, widespreadF812Nov 3, 2022

  Based on observation, interview, and document review the facility failed to have a system in place to monitor and record refrigerator temperatures for resident personal food items. This had the potential to affect all 28 residents. The facility also failed to have a process in place to indicate proper food storage of butter blend product and cheese products. This had the potential to affect 27 of 28 residents who receive food prepared with the butter product and cheese products. Findings include: During an observation and interview on 11/2/22, at 5:01 p.m. temperature log on refrigerator designated for resident food items indicated temperatures at 42 degrees and 44 degrees on 10/16/22. Temperature log lacked temperature verification from 10/17/22 through 11/2/22. […]

• No harm, potential for more than minimal, patternF600May 25, 2022

  Based on interview and document review, the facility failed to ensure residents were free from verbal and physical abuse for 6 of 6 residents (R1, R2, R3, R4, R5, R6) who were involved in resident to resident verbal and/or physical altercations involving R1. Further, the facility failed to ensure allegations of resident to resident verbal and physical abuse were thoroughly investigated, assessed, and interventions care planned to ensure residents in the vicinity of R1 were safe after R1 demonstrated an escalation in verbal and physically aggressive behaviors directed at other residents in the facility. […]