Bell Trace Health and Living Center

In the surveyor’s words

From the most serious findings on record at Bell Trace Health and Living Center, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 23, 2021

  Based on interview and record review, the facility failed to ensure a nurse administered medications to the correct resident, which resulted in the resident having received another resident's medication and change in health status that required inpatient intensive care hospitalization for 1 of 5 residents reviewed for medication administration (Resident B). The deficient practice was corrected on February 16, 2021, prior to the start of the survey, and was therefore Past Noncompliance. Findings include: On 2/22/21 at 2:15 p.m., Resident B's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF812Sep 13, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 2 of 2 kitchen observations. Food was stored under a water line which had condensed water. Findings include: On 9/10/24 at 10:50 a.m., food was observed in the kitchen walk-in freezer on shelving beneath a condenser line upon which large portions of ice had formed. The ice portions were on and in a large box of packaged brussel sprouts and a large box of packaged mixed vegetables. On 9/13/24 at 1:50 p.m., food was observed in the kitchen walk-in freezer on shelving beneath a condenser line upon which large portions of ice had formed. The ice portions were on and in a large box of packaged brussel sprouts and a large box of packaged mixed vegetables. […]

• No harm, potential for more than minimal, isolatedF641Sep 13, 2024

  Based on record review and interview, the facility failed to ensure an accurate MDS (Minimum Data Set) assessment for 1 of 5 residents reviewed for unnecessary medications. The Admission MDS assessment lacked documentation of an anxiety diagnosis. (Resident 65) Finding includes: On 9/12/24 at 2:00 p.m., Resident 65's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, anxiety disorder, hypertension, and pain. A review of the Admission MDS assessment, dated 7/9/24, anxiety disorder was not marked as an active diagnosis. […]

• No harm, potential for more than minimal, isolatedF761Sep 13, 2024

  Based on observation, interview, and record review, the facility failed to ensure medications were stored properly for 2 of 3 medication rooms observed. Medications were not labeled with an open date and expired medications were not disposed of. (Skilled 3 Rehabilitation Medication Room, Skilled 1 Medication Room). Findings include: On 9/13/24 at 11:56 a.m., the refrigerator in the Skilled 3 Rehabilitation 1 Medication Room was observed to have a vial of tuberculin PPD (medication used to test for tuberculosis) and a vial of Humalog (insulin) without an open date. The Director of Nursing (DON) could not find an open date on the vials. On 9/13/24 at 12:04 p.m., the refrigerator in Skilled 1 Medication Room was observed to have a vial of tuberculin PPD opened and dated 4/16/24. […]

• No harm, potential for more than minimal, isolatedF880Sep 13, 2024

  Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 3 residents reviewed for urinary catheters. Urinary catheter tubing was observed on the floor. (Resident 14) Findings include: On the following dates, times, and locations, Resident 14 was observed in his wheelchair with his urinary catheter tubing beneath the wheelchair and lying on the floor: - On 9/11/24 at 10:55 p.m., in the resident's room. - On 9/12/24 at 1:30 p.m., on the front outside patio. - On 9/12/24 at 2:46 p.m., at the resident common room/puzzle station. On 9/11/24 at 11:15 am, Resident 14's clinical record was reviewed. The diagnoses included, but were not limited to, heart failure and acute kidney failure. […]