Bell Avenue Nursing Center

In the surveyor’s words

From the most serious findings on record at Bell Avenue Nursing Center, in the surveyor’s own words.

• Actual harm, patternF600Aug 22, 2024

  Based on record review and interview, the facility failed to provide an environment free from abuse for two (#7 and #8) of five sampled residents reviewed for resident-to-resident abuse. The Administrator identified 56 residents resided in the facility. Findings: An 'Abuse Prevention Program' policy, revised September 2015, read in parts, .It is the policy of the facility to prohibit abuse .The facility will investigate allegations and reported incidents .The investigation will include preventative measures when possible to prevent reoccurrence .Examples of plans of action may include a change in care, a change in medication . 1. Resident #6 A document titled Annual MDS Assessment, dated 06/24/24, Resident #6 cognition was severly impaired. […]

• No harm, potential for more than minimal, patternF636Mar 26, 2025

  Based on record review and interview, the facility failed to conduct a comprehensive assessment within 14 calendar days of admission for 2 (#104 and #205) of 13 sampled residents reviewed for comprehensive assessments. The administrator reported 51 residents resided in the facility. Findings: A MDS Completion and Submission Timeframes policy, dated July 2017, read in part, Our facility will conduct and submit resident assessments with current federal and state submission timeframes. 1. Resident #104 had diagnoses which included acute osteomyelitis, right tibia and fibula, encounter for closed fracture with nonunion, and chronic obstructive pulmonary disease. […]

• No harm, potential for more than minimal, patternF641Mar 26, 2025

  Based on record review and interview, the facility failed to ensure assessments were accurate for 2 (#37 and #46) of 2 sampled residents reviewed for anticoagulant therapy. The administrator reported 51 residents resided in the facility. Findings: The facility had no policy for coding medication on MDS assessments. 1. Resident #37 had diagnosis which included cerebrovascular accident. A physician order, dated 05/09/24, showed to give the clopidogrel bisulfate (antiplatelet medication), 75 mg by mouth one time a day for cerebrovascular accident. The physician orders contained no anticoagulant medication. A quarterly assessment, dated 12/24/24, showed resident #37's cognition was moderately impaired with a BIMS score of 11. […]

• No harm, potential for more than minimal, patternF689Dec 17, 2024

  Based on record review and interview, the facility failed to ensure accurate wandering risk scale assessments were completed for two (#2 and #3) of three residents sampled for accurate wandering risk scale assessments. The DON identified eight residents were at risk for wandering and elopement. Findings: The facility's Elopement and Wandering Residents policy, dated 01/13/21, read in part, Wandering is random or repetitive locomotion that may be goal directed (e.g., the person appears to be searching for something such as an exit) or non goal directed or aimless. […]

• No harm, potential for more than minimal, patternF755Apr 20, 2023

  Based on record review and interview, the facility failed to establish a system of records of receipt and disposition, of controlled drugs, to enable an accurate reconciliation for one (#2) of one resident reviewed for disposition of controlled drugs upon discharge. The Resident Census and Conditions of Residents report, dated 04/19/23, identified 47 residents who resided in the facility. Findings: A Documentation of Transfers/Discharges, dated April 2007, read in parts, .All documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record .Documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply .Disposition of medications . […]