Belmont Terrace Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Belmont Terrace Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580May 14, 2021

  Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure the Physician was notified when there was a significant change in condition and a need to alter treatment for one (1) of thirty (30) sampled residents (Resident #110). The facility admitted Resident #110, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #110 was hospitalized , on [DATE], with Altered Mental Status, Condition Decline, and [CONDITION(S)]. Prior to the [DATE] acute care hospitalization , the resident was receiving Oxycodone with Acetaminophen (a narcotic opioid [MEDICATION(S)] given for moderate to severe pain) on a every six (6) hour schedule. […]

• Immediate jeopardy, isolatedF656May 14, 2021

  Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, it was determined the facility failed to ensure Comprehensive Care Plans (CCP) for chronic pain and pressure risk with individualized person-centered interventions were followed for four (1) of thirty (30) sampled residents, Resident #110, #114, #36 and #102. The facility identified Resident #110 as at risk for alterations in comfort related to [CONDITION(S)] (OA), muscle weakness, right upper extremity [CONDITION(S)], contracture, [CONDITION(S)], obesity, and polyneuropathy. […]

• Immediate jeopardy, isolatedF657May 14, 2021

  Based on interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, it was determined the facility failed to ensure Comprehensive Care Plans (CCP) were reviewed and revised to address the need for additional interventions to monitor and maintain sufficient respiratory status for one (1) of thirty (30) sampled residents (Resident #110). The facility admitted Resident #110, on [DATE] with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #110 had been hospitalized , from [DATE] to [DATE] with [CONDITION(S)] and Acute Respiratory Failure. […]

• Immediate jeopardy, isolatedF661May 14, 2021

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the discharge summary process included reconciliation of all pre-discharge medications with the resident's post-discharge medications, both prescription and over-the-counter, and the resident was discharged with the correct medications for one (1) of thirty (30) sampled residents (Resident #81). The facility admitted Resident #81, on 03/12/2021, for short-term rehabilitation. On 05/05/2021, the Physician ordered to discharge Resident #81 home with medications. […]

• Immediate jeopardy, isolatedF686May 14, 2021

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure skin assessments were completed to identify/monitor for skin breakdown along pressure ulcer prevention interventions according to standards of practice to prevent further decline for one (1) of thirty (30) sampled residents, Resident #110. On [DATE], Resident #110 was transferred to the hospital by Emergency Medical Services (EMS) and during the triage period hospital staff and EMS identified a sacral wound. The hospital assessed the resident to have an open right gluteal abscess measuring three (3.0) centimeters (cm) and draining copious amounts of purulent material. […]