Belvidere Health and Rehab

In the surveyor’s words

From the most serious findings on record at Belvidere Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 27, 2021

  Based on observation, interview, and record review, the facility failed to ensure a resident (R1) was free from mental abuse, failed to ensure a resident (R2) was not denied goods to maintain comfort. These failures resulted in R1 experiencing increased emotional lability and R2 experiencing increased anxiety and anger. These failures apply to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 3. The Immediate Jeopardy began on 10/16/21 when V3 Registered Nurse restrained R1 in his room by holding the door shut not allowing R1 to exit his room. The Immediate Jeopardy was identified on 10/20/21. V1 (Administrator) was notified of the Immediate Jeopardy on 10/26/21 at 11:38AM. […]

• Actual harm, isolatedF610Oct 27, 2021

  Based on observation, interview, and record review, the facility failed to protect a resident (R1) from further potential abuse during an abuse investigation after an allegation was made regarding potential abuse from a nurse. The facility failed to remove a staff member alleged of abuse from working prior to the completion of an abuse investigation. The nurse witheld care to R2 by not providing a blanket. These failures contributed to a nurse having access and withholding care to R1 and R2. R1 was experiencing crying episodes, increased anxiety, increased obsessions, fear of being discharged from the facility, and fear of V3 (Registered Nurse) taking care of him. R2 experienced increased anxiety and anger. […]

• Actual harm, isolatedF760Oct 27, 2021

  Based on interview and record review, the facility failed to provide a resident (R1) with an antipsychotic medication for 19 days after returning to the facility from an inpatient psychiatric stay at a local mental health facility. This failure resulted in R1 continuing to experience sexual and obsessive behaviors. This failure applies to 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's electronic face sheet printed on 10/21/21 showed R1 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan dated 9/25/20 showed, (R1) demonstrates significant mood distress related to [CONDITION(S)] and major depressive disorder. […]

• No harm, potential for more than minimal, widespreadF725Jun 13, 2024

  Based on interview and record review the facility failed to ensure sufficient Certified Nursing Staffing from October through December of 2023. This has the potential to affect all residents residing in the facility. The findings include: The facility's document CMS form 671 dated 6/11/24 showed 53 residents residing in the facility. The facility's Facility assessment dated [DATE] showed under nursing services that the number of CNAs (Certified Nursing Assistants) on the evening shift should be 4. The facility's October 2023 CNA schedule showed on 10/7/23, 10/14/23, 10/15/23 10/21/23, 10/22/23, 10/28/23 and 10/29/23 there were 2.5 CNAs scheduled on the evening shift. […]

• No harm, potential for more than minimal, widespreadF812Aug 9, 2023

  Based on observation, interview, and record review the facility failed to ensure the facility's ice machine was free of a black mold like substance. This has the potential to impact all 53 residents residing in the facility. The findings include: The CMS 672 Resident Census and Conditions of Residents form dated 8/7/23 shows the total number of residents within the facility is 53. On 8/9/2023 at 10:40AM, the facility's ice machine was observed to have black mold like spots on a plastic piece of the machine above the ice hopper full of ice. There was also a black mold like substance on a seal at the top of the ice hopper folding door. On 8/9/2023 at 10:50AM, V4 said the ice machine was the only ice machine in the building. […]