Belvedere Nursing and Rehabilitation Center, LLC

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Oct 13, 2023

  Based on record review and interview, the facility failed to develop and implement a water management program to prevent the likelihood of waterborne illnesses caused by opportunistic pathogens such as Legionella. This failed practice had the potential to affect all 114 residents in the facility based on the Midnight Census Report which was provided by the Administrator on 10/4/23 at 10:15 a.m. These findings were determined to be Immediate Jeopardy. The Surveyor provided the State Operations Manual Appendix Q Immediate Jeopardy template to the Administrator and informed of the Immediate Jeopardy on 10/5/23 at 2:43 PM. […]

• Actual harm, isolatedF689Mar 14, 2025

  Based on observation, record review, and interview, the facility failed to ensure staff followed care planned interventions requiring one staff member to perform transfers with gait belt to promote resident safety and prevent injury for 1 (Resident #2) of 3 sampled residents who required one-person transfers with a gait belt. This failed practice resulted in actual harm for Resident #2, who was transferred without the use of a gait belt and sustained a dislocation of the shoulder, proximal humerus fracture, ligamentous injury, and clavicle injury. The findings are: 1. […]

• Actual harm, isolatedF689Dec 21, 2023

  Based on observation, record review, and interview, the facility failed to implement interventions for previous falls as indicated from the care plan to decrease the potential for future falls with injuries which resulted in a fall with a fracture for 1 (Resident #53); This failed practices had the potential to affect 23 residents who were at risk for falls according to a list provided by the Assistant Director of Nursing on 12/21/23 at 10:39AM. The facility failed to ensure residents who were at risk for fluid aspiration had the correct thickened consistency per physician's orders for 2 of 2 (#85 and #89). The Findings are: 1a. Resident #53 had a fall on 08/02/23 resulted in a radius fracture, ulnar fracture, seventh and eight rib fractures. b. […]

• Actual harm, isolatedF689Nov 30, 2022

  Based on record review and interview, the facility failed to ensure a cognitively impaired resident was adequately supervised when drinking hot liquids which resulted in an injury for 1 (Resident #5) and failed to supervise a cognitively impaired resident who got a hot curling iron from behind the nurses station for 1 (Resident #4) of 5 (Residents #1, #2, #3, #4 and #5) sampled residents who resided on the Secure Unit. This failed practice had the potential to affect all 23 residents residing on the Secure Unit as documented on the Census provided by the Administrator on 11/28/22 at 10:18 a.m. The findings are: 1. Resident #5 had diagnosis of Vascular Dementia. […]

• No harm, potential for more than minimal, widespreadF812Sep 28, 2022

  Based on observation and interview, the facility failed to ensure 1 of 2 ice machines and scoop holders were maintained in clean condition to prevent the potential contamination of residents' food or beverages; staff washed their hands before handling clean equipment or food items to prevent potential for cross contamination; foods stored in the freezer were covered and sealed; expired food items were promptly removed and discarded on or before the expiration date, and food items stored in the dry storage area were dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen. […]