Belvedere Center, Genesis Healthcare, The

In the surveyor’s words

From the most serious findings on record at Belvedere Center, Genesis Healthcare, The, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 23, 2024

  Based on a review of the facility's policy, facility documentation, clinical records, and staff interview, it was determined that the facility failed to monitor resident's skin condition and follow wound physician's treatment orders/recommendations resulting in harm to Resident CL1 of discovering the wound at an advanced Stage 3 (full thickness loss of skin that extends into the subcutaneous tissue but does not cross the fascia beneath), wound deterioration, and unnecessary pain/discomfort for one of two residents reviewed (Resident CL1). Findings include: Review of the facility's policy titled Skin Integrity and Wound Management, reviewed May 1, 2024, revealed that nursing assistants will observe skin daily and report any changes or concerns to the nurse. […]

• Actual harm, isolatedF600Oct 6, 2023

  Based on review of facility policy, facility investigative documentation, clinical and hospital records, it was determined that the facility failed to ensure one of 24 residents was free from neglect, which resulted in actual harm to Resident 120, through Employee E3's failure to report a fall to registered nurse, the resident experienced a delay in assessment, treatment, and subsequent hospitalization for intracranial hemorrhage (brain bleed) resulting in death. Findings include: Review of facility policy, Abuse Prohibition, last revised [DATE], revealed: Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental… […]

• Actual harm, isolatedF686Oct 6, 2023

  Based on review of the facility's policy, clinical record reviews, and staff interviews, it was determined that the facility failed to monitor and provide wound treatment timely and consistently resulting in harm of a new pressure ulcer discovered at an advanced stage (Stage 3- Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue) for one of nine residents reviewed (Resident 54). Findings include: Review of facility policy titled Skin Integrity and Wound Management, dated February 1, 2023, revealed the purpose is to provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing within the context of what matters most to all patients. […]

• No harm, potential for more than minimal, widespreadF812Oct 6, 2023

  Based on observation, and staff interviews, it was determined that the facility failed to maintain, and prepare food by professional standards and maintain sanitary conditions in the kitchen area. Findings include: Observations conducted during initial tour of the kitchen on September 26, 2023, at 9:35 a.m., in the presence Dietary manager, Employee 5 revealed the following: The stainless steel grill machine was observed with a build-up black substance inside the oil trap container and to its surroundings. […]

• No harm, potential for more than minimal, patternF761Jul 16, 2026

  Based on a review of the facility's policy and the medication manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to ensure medications were properly labeled and stored on one of three units observed (South Unit Front Medications Cart, South Unit Middle Medication Cart, and South Unit Medication Room). Findings: A review of the facility policy titled Medications and Medication Labels, undated, revealed, Medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use following state and federal laws. […]