Belleair Health Care Center

In the surveyor’s words

From the most serious findings on record at Belleair Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Aug 27, 2021

  Based on observation, interview, review of temperature recording logs and review of policies and procedures, the facility failed to ensure that cold Time/Temperature Control for Safety (TCS) food was held at 41 degrees Fahrenheit (F) or below during the lunch meal service on 8/26/21. The affected food was intended to be served to 8 residents out of 104 residents who consumed the facility's prepared food. The findings included: On 08/26/21 at 12:06 PM, during the lunch meal service, there was a tray of approximately 17 individual butterscotch puddings held without ice or cooling device. The surveyor took the holding temperature of an individual butterscotch pudding from this tray, using the facility's thermocouple, and the temperature was 55 degrees F, rather than at 41 degrees F or below. […]

• No harm, potential for more than minimal, isolatedF656Aug 15, 2025

  Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for one resident (#93) of two residents sampled for nutrition.Findings include: On 08/12/25 at 2:25 PM an observation was made of Resident #93. The resident was observed with a pink NPO (nothing by mouth) wrist band to right wrist and was noted to be drinking from a cup at the bedside. Resident #93 said family had provided the cup, and he was aware he was not supposed to be drinking from it, but he was thirsty.Review of Resident #93's medical record revealed a physician's order dated 07/27/25 and no end date for NPO diet, NPO texture, NPO consistency.Review of Resident #93's care plan with a revision date of 07/15/25 revealed [Resident #93] has a… […]

• No harm, potential for more than minimal, isolatedF684Aug 15, 2025

  Based on observations, interviews, and record review the facility failed to provide appropriate wound care by not following professional standards of care for one resident (#87) of three residents sampled for non-pressure related skin conditions.Findings included: On 08/12/25 at 1:45 PM an interview was conducted with Resident #87, who said he was here at the facility due to a wound on the right foot that became infected prior to admission to the facility. Observation of the resident's right foot revealed the right foot was covered in a gauze dressing and dated 08/12/25. Resident #87 said the dressing had been changed earlier today.An observation was conducted on 08/13/25 at 12:00 PM of Resident #87's right foot covered in a gauze dressing dated 08/13/25. […]

• No harm, potential for more than minimal, isolatedF688Aug 15, 2025

  Based on observation, interview, and record review the facility failed to ensure splints were applied according to physician orders for one resident (#14) out of one resident reviewed for splints.Findings included: An observation was conducted on 08/12/2025 at 1:52 PM. Resident #14 was lying in bed asleep with covers up to neck with both hands exposed. Resident #14 was observed to have a right-hand contracture with no splint in place. An observation was conducted on 08/14/2025 at 9:43 AM. Resident #14 was in bed watching television. The right hand was contracted with no splint or washcloth in place. Review of Resident #14's physician orders revealed an order dated 08/13/25 Restorative Nursing for splinting. […]

• No harm, potential for more than minimal, isolatedF761Aug 15, 2025

  Based on observations and interviews the facility failed to provide proper storage of medications for two residents (#93 and #11) of 38 sampled residents. Findings included: On 8/12/25 at 2:33 PM an observation was made of a bottle of “Dakin's Solution quarter strength” (a pharmacy grade bleach solution to treat wounds) was noted on Resident #93's dresser in his room. On 08/13/25 at 1:13 PM an observation was made of Resident's #93's dresser and revealed the bottle of “Dakin's Solution” was still present in the resident's room. On 08/13/25 at 1:14 PM an interview was conducted with Nurse F, a Licensed Practical Nurse who confirmed that the bottle of “Dakin's Solution” should not be kept on the resident's dresser in the room but should be stored on the treatment cart. […]