Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belleview Care Center during CMS and state inspections, most recent first.
The facility did not provide required quarterly statements of resident trust fund accounts to residents or their representatives for at least four individuals, as confirmed by record review and staff interviews. This failure was contrary to facility policy, which mandates quarterly and upon-request reporting of such accounts.
A resident with a history of aggression and cognitive impairment pushed another resident, who was at risk for falls, to the floor after feeling blocked in a corridor. The incident resulted in minor pain for the resident who was pushed, and staff witnessed and assessed the situation immediately. The event constituted a failure to protect a resident from physical abuse, despite facility policies and known behavioral risks.
A resident with cognitive impairments and aggressive behavior struck three other residents in separate incidents, involving physical aggression such as punching and slapping. Despite being on one-to-one monitoring, staff failed to prevent these altercations. The aggressive resident had a history of Alzheimer's disease and was known for behaviors that put others at risk. The facility's policy on abuse prevention was not effectively implemented, leading to a failure to protect residents from abuse.
The facility failed to meet professional standards for food safety and sanitation, with issues such as unlabeled and expired food, improper storage, and unsanitary kitchen conditions. Staff demonstrated improper handwashing techniques, and there was a lack of adherence to food safety policies, as confirmed by interviews with staff members.
The facility failed to maintain residents' dignity and preferences in grooming and bathing. Three residents with cognitive impairments were observed with unshaven facial hair, and a cognitively intact resident expressed dissatisfaction with infrequent showers. Staff interviews revealed inconsistencies in adhering to facility policies, with expectations for grooming and bathing not consistently met.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as uncovered suction machines, damaged furniture, and unaddressed maintenance problems like unpainted patches and broken window blinds. Staff interviews revealed a lack of clarity in responsibilities and a gap in executing maintenance processes.
The facility failed to provide adequate perineal care for three dependent residents, as staff did not separate and clean all perineal folds during care. Despite being aware of the proper procedures, CNAs did not adhere to the facility's policy, affecting residents with specific needs due to incontinence and mobility limitations.
The facility failed to ensure proper medication administration and respect resident preferences, leading to deficiencies. A resident with cognitive impairment received medications from their spouse without proper authorization, while another resident's preference for more frequent showers was not met due to staffing issues.
The facility exceeded the acceptable medication error rate, reaching seven percent due to improper administration of artificial tears to two residents. The CMT allowed the dropper tip to touch the resident's eyelid and eyelashes and applied lacrimal pressure for an insufficient duration. The facility's policy lacked specific guidelines for eye drop administration.
Two residents reported dissatisfaction with the palatability and presentation of food, which was sometimes served cold and unappetizing. The facility lacked a policy on food palatability and appearance, despite expectations for food to be served at appropriate temperatures and with appealing presentation.
The facility failed to maintain the walk-in freezer in a safe condition, with ice build-up and elevated temperatures observed. Food items were found thawed, and temperature logs were inconsistent. Staff interviews revealed a lack of clear procedures for addressing equipment malfunctions.
Two residents with cognitive impairments were found without accessible call lights, preventing them from summoning staff assistance. Observations showed one resident's call light was under the bed, while another's was clipped to the wall out of reach. Staff interviews confirmed the expectation for call lights to be within reach.
A resident's DNR order contained conflicting information, with signatures both authorizing and revoking life-saving measures. Despite being documented in multiple places, staff were uncertain about the resident's code status due to these inconsistencies. The Social Services Designee was responsible for ensuring DNR accuracy, but the oversight led to unclear documentation of the resident's wishes.
A facility failed to document the administration of pain medications for a resident, leaving blank spaces on the MAR. Staff interviews confirmed that documentation was missing, making it unclear if medications were given, refused, or unavailable. The resident reported severe pain and periods without medication.
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in following physician orders and maintaining clean equipment. One resident with severe cognitive impairment was not provided with continuous oxygen therapy as ordered, and staff were unaware of the active order. Another resident with dementia and respiratory failure had a dirty oxygen concentrator with outdated tubing. Staff interviews confirmed that physician orders should be followed and equipment cleaned before use.
A resident with no cognitive deficits was forcibly fed by a CNA despite expressing a desire not to eat, leading to emotional distress and fear of choking. The CNA, aware of resident rights, believed they were helping due to the resident's perceived weakness. The incident was reported by the resident and staff, but the Administrator did not classify it as abuse, though acknowledged inappropriate actions.
The facility failed to maintain a safe environment by not addressing a leak in a resident room and adjacent utility room, leading to water accumulation and mold growth. Staff interviews indicated the leak had persisted for weeks, with inadequate measures to prevent resident access. The administrator and corporate nurse were unaware of the mold, and the roof replacement contract did not cover necessary repairs.
A resident reported being force-fed by a CNA during an evening meal, despite being capable of self-feeding and expressing a desire not to eat. The incident was reported to an LPN, who informed the Administrator. However, the Administrator did not report the incident to the State Agency, considering it a customer service issue rather than abuse, which violated the facility's policy requiring timely reporting of alleged abuse.
A resident reported being force-fed by a CNA, but the facility failed to conduct a thorough investigation as required by its policy. The resident, who did not need assistance with eating, expressed refusal, but the CNA continued to push food into their mouth. The Administrator did not immediately investigate or obtain staff statements, considering it a customer service issue rather than abuse.
Staff did not notify the physician when a resident with a liver transplant and cognitive impairment refused antirejection medication and food for multiple days, despite facility policy requiring notification of significant changes and medication refusals. The resident exhibited signs of illness, and the physician later confirmed he was not informed of the missed doses.
The facility failed to maintain a safe, clean, and comfortable environment in the memory care unit by not addressing multiple holes in the ceiling. Observations revealed various open and covered holes, and interviews confirmed that the Director of Maintenance and the Administrator were aware of the issue but unsure when repairs would be completed. The facility census was 82, with 22 residents in the memory care unit affected.
Failure to Provide Quarterly Resident Trust Fund Accountings
Penalty
Summary
The facility failed to maintain a system to ensure accurate quarterly accounting of resident trust fund (RTF) accounts was provided to residents or their representatives. Record review showed that for four sampled residents, quarterly RTF statements had not been sent to the residents' representatives in the previous six months, despite facility policy requiring such statements to be provided within 30 days after the end of each quarter and upon request. The policy also required that any transaction involving resident funds be documented with a receipt and that the business office maintain copies of each transaction. Interviews with the Business Office Manager (BOM) and the Facility Regional Consultant confirmed that the BOM had not been sending the required quarterly RTF reports to residents or their representatives. Both acknowledged that the BOM was responsible for this task and that the reports could be provided in writing or electronically. The facility census at the time was 84, and the deficiency affected all four sampled residents.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of physical aggression and impaired cognition pushed another resident to the floor, resulting in a violation of the right to be free from physical abuse. The aggressive resident had diagnoses including dementia, neurocognitive disorder, and poor impulse control, and was known to become physically aggressive with both staff and other residents. At the time of the incident, the resident was experiencing a urinary tract infection, which staff believed may have contributed to the behavior. The incident took place in a corridor when the aggressive resident, feeling blocked by the other resident, used both hands to shove the individual in the chest, causing a fall. The resident who was pushed had Alzheimer's disease, dementia, and was at risk for falls, with a care plan indicating a need for safety monitoring. This resident did not have a history of aggression towards others. After being pushed, the resident fell backwards and reported minor pain near the thigh and pelvic area but did not recall the details of the incident. Staff present at the time witnessed the event and immediately assessed the resident for injuries. The facility's policy required protections against all forms of abuse, including physical abuse, and outlined the need for assessments and interventions for residents with behavioral risks. Despite these policies and the known behavioral history of the aggressive resident, the incident occurred, resulting in a failure to protect a resident from physical abuse by another resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse when a resident with cognitive impairments and aggressive behavior struck three other residents. The incidents involved physical aggression, including punching and slapping, which occurred in the dining room and involved residents with varying degrees of cognitive impairment and dependency on staff for activities of daily living. The aggressive resident had a history of Alzheimer's disease, depression, and diabetes mellitus, and was known for physical and verbal behaviors that put others at risk. The first incident involved the aggressive resident stepping on the cord of another resident's breathing treatment machine, leading to a verbal altercation and a physical attack. The second incident occurred when the aggressive resident attempted to push another resident in a wheelchair and struck them on the cheek before staff could intervene. The third incident involved a similar scenario where the aggressive resident attempted to push a resident in a wheelchair and slapped them on the cheek. Staff interviews revealed that the aggressive resident was on one-to-one monitoring, yet staff failed to prevent the physical altercations. The Director of Nursing acknowledged that the resident communicated through physical touch and that the actions were deliberate, even if not intended to harm. The facility's policy on abuse, neglect, and exploitation was not effectively implemented to prevent these incidents, resulting in a failure to protect residents from abuse.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in food storage, preparation, and sanitation practices. Observations revealed that staff did not label and date all food items, leading to expired goods such as spices and shortening remaining in storage. Additionally, open food items were not sealed or covered, increasing the risk of contamination. The facility also neglected to maintain accurate temperature logs for refrigerators and freezers, and staff were unaware of the location of the dishwasher chemical sanitizer test log. The kitchen environment was found to be unsanitary, with greasy and slippery floors, dirty ceiling vents, and water stains on the ceiling. Plates and containers were improperly stored face up, and empty boxes cluttered the floor, obstructing access to the handwashing sink. The facility's sanitation policy was not followed, as evidenced by the presence of dark spatters on the ceiling and peeling paint and drywall near the walk-in freezer. Staff demonstrated improper handwashing techniques, with the Dietary Manager using the same paper towel to dry hands and turn off the faucet, leading to re-contamination. Additionally, a dietary aide was observed with a beard cover that did not fully cover chin hair, violating hygiene standards. Interviews with staff, including the Dietary Manager and Dietician, confirmed a lack of adherence to expected food safety and sanitation practices, contributing to the deficiencies observed during the survey.
Failure to Maintain Resident Dignity and Preferences in Grooming and Bathing
Penalty
Summary
The facility failed to maintain residents' rights to dignity and personal preferences, particularly in the grooming and bathing of residents. Three residents with cognitive impairments were observed with unshaven facial hair, despite the facility's policy to assist with grooming to maintain hygiene and dignity. Resident #11, with mild cognitive impairment and a terminal prognosis, was repeatedly observed with half-inch facial hair over several days. Similarly, Resident #64, with moderate cognitive impairment and Alzheimer's, was also seen with half-inch facial hair on multiple occasions. Resident #21, with significant cognitive impairment and total assistance needs, was observed with 1-2 inch facial hair and dried food on their face and chair, indicating a lack of personal hygiene assistance. Additionally, the facility did not honor the bathing preferences of Resident #16, who is cognitively intact and requires moderate assistance with ADLs. The resident expressed dissatisfaction with the infrequency of showers, receiving only one shower in ten days, despite a preference for two to three showers per week. Interviews with staff revealed inconsistencies in the provision of showers, with some staff acknowledging the lack of a shower aide and the expectation that residents should receive at least two showers weekly. Interviews with facility staff, including nursing assistants and licensed practical nurses, highlighted a lack of adherence to the facility's policies regarding grooming and bathing. Staff acknowledged that residents should be offered shaves on bath days and that equipment should be cleaned when dirty. The Director of Nursing and the Administrator confirmed the expectation for residents to be well-groomed and to receive showers twice a week, with additional showers provided upon request. However, these expectations were not consistently met, leading to the deficiencies observed.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations and interviews. In the memory care unit, uncovered suction machines with visible debris were found in a common area, and a chair with a ripped cushion was located near the nurses' station. The main hallway and dining area floors were noted to have a dull finish and were sticky. Interviews with staff revealed a lack of clarity regarding responsibility for medical equipment storage and maintenance of furniture. Additionally, the facility had issues with unpainted patches on walls, missing light bulbs, and water stains on ceilings in various rooms, indicating a lack of timely maintenance and repair. Further observations highlighted broken window blinds, loose headboards and footboards on beds, and damaged furniture in resident rooms. The maintenance director mentioned a computer-based preventative maintenance program and a process for submitting work orders, but the presence of these deficiencies suggests a gap in execution. Interviews with the DON and the Regional Housekeeping Manager confirmed that nursing and housekeeping staff are aware of the process for reporting maintenance issues, yet the deficiencies persisted, indicating a failure in maintaining the facility's physical environment as per their policies.
Inadequate Perineal Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This deficiency was observed in three residents who were dependent on staff for all activities of daily living and had specific needs for perineal care due to incontinence. The facility's policy required that all areas affected by urine or feces be thoroughly cleaned, including separating and cleaning all perineal folds, which was not adhered to by the staff. For Resident #10, who had no cognitive impairment but was dependent for all ADLs and had a urinary catheter, the staff did not separate and clean all perineal folds during care. Similarly, Resident #39, who was also dependent for all ADLs and had multiple sclerosis and arthritis, did not receive complete perineal care as staff failed to clean all necessary areas. Resident #25, with moderate cognitive impairment and always incontinent of bowel and bladder, also did not receive adequate perineal care as staff did not separate and clean all perineal folds. Interviews with the CNAs involved revealed that they were aware of the proper procedures for perineal care but did not follow them during the observed instances. The Director of Nursing and the Administrator confirmed the expectations for perineal care, emphasizing the need to clean all areas affected by urine or feces. Despite this, the deficiency in providing complete perineal care was evident in the observations and interviews conducted.
Deficiencies in Medication Administration and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate care and services for three residents, leading to deficiencies in medication administration and respecting resident preferences. Resident #47, who is cognitively impaired with diagnoses of dementia and Alzheimer's disease, had medications left in a cup on their desk, which were administered by their spouse, Resident #48, without a physician's order or competency assessment. Resident #48, who has moderate cognitive impairment and multiple health issues, including heart and lung disease, was given the responsibility to administer medications to Resident #47, despite the lack of proper authorization and documentation. Additionally, the facility did not respect Resident #16's preference for shower frequency. Resident #16, who is cognitively intact but requires moderate assistance for activities of daily living and is dependent on a wheelchair, expressed dissatisfaction with receiving only one shower per week instead of the preferred two to three showers. The resident reported that the facility often lacked a shower aide, which contributed to the infrequent showers. Interviews with staff confirmed that residents should receive showers twice a week, with the option for more if requested, but this was not consistently provided.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a seven percent error rate. This was observed when staff made two medication errors out of 26 opportunities, affecting two residents. The errors involved the administration of artificial tears eye drops, where the Certified Medication Technician (CMT) allowed the dropper tip to touch the resident's eyelid and eyelashes, which is against proper procedure. The facility's policy for medication administration was undated and did not include specific guidelines for the administration of eye drops. During the observation, the CMT washed hands, applied gloves, cleaned the resident's eyelids, and then placed a drop in the resident's eye, but the dropper tip made contact with the eyelid and eyelashes. The CMT also applied lacrimal pressure for only 20 seconds, whereas the correct procedure requires one to two minutes. Interviews with the CMT and the Director of Nursing confirmed that the dropper tip should not touch the resident's eye and that lacrimal pressure should be applied for a longer duration.
Deficiency in Food Palatability and Presentation
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and attractive, as observed in the cases of two residents. Observations on February 11, 2025, revealed that the Alfredo noodles were dry and bland, and the cream pie dessert had a gritty texture and was tasteless. Resident #16, who is cognitively intact and has diagnoses including debility, heart disease, diabetes, depression, and lung disease, reported that food was sometimes served cold and raw, and they did not receive the drinks they ordered. The resident expressed dissatisfaction with the presentation of the food, which affected their willingness to eat. Resident #8, also cognitively intact with diagnoses of diabetes, anxiety, depression, and lung disease, reported that the food was not good and was cold upon delivery. The resident found the food unappetizing and resorted to eating snacks in their room. They expressed frustration with the repetitive menu options and described an instance where the waffles served were too hard to eat. Interviews with the Dietary Manager, Dietician, and Senior Administrator confirmed expectations for food to be served at appropriate temperatures and with appealing appearance, seasoning, and texture. However, the facility did not provide a policy on food palatability and appearance.
Failure to Maintain Safe Freezer Conditions
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe and operable condition, specifically the large walk-in freezer. Observations revealed a significant build-up of ice on the freezer floor and ceiling, leading to elevated temperatures within the freezer for several days. The internal thermometer read 28 degrees Fahrenheit, and the external thermometer read 12 degrees Fahrenheit, both above the FDA's recommended 0 degrees Fahrenheit. Food items such as chicken nuggets, ice cream cups, and pizza rolls were found to be softer and warmer than expected, indicating potential thawing. Temperature logs were missing for certain days, and discrepancies were noted between recorded temperatures and those observed on the thermometers. Interviews with dietary staff and the maintenance director highlighted a lack of consistent procedures for addressing freezer malfunctions. Dietary staff acknowledged that freezer temperatures should be at or below 0 degrees Fahrenheit and that any ice build-up should prompt a maintenance request. However, the maintenance director was only notified of the issue on the last day of the observed period, and a repair company was called in to address the problem. The senior regional administrator provided conflicting information, suggesting that freezer temperatures should be between 32 to 34 degrees Fahrenheit, further indicating a lack of clear guidelines and communication within the facility.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident #36 and Resident #79, had access to a call light while lying in bed, which is necessary for summoning staff assistance. Resident #36, who has severe cognitive impairment and requires total assistance with activities of daily living, was observed without a call light within reach. The call light was found behind a curtain and underneath the bed, making it inaccessible. During an interview, Resident #36 was unaware of the presence of a call light and did not know how to contact a nurse if assistance was needed. Staff interviews confirmed that call lights should be within reach of residents. Similarly, Resident #79, who has moderate cognitive impairment and is unable to communicate needs effectively, was observed with the call light clipped to the wall at the head of the bed, out of reach. The resident also did not know how to call for a nurse. Interviews with staff, including a CNA, LPN, and the Director of Nursing, reiterated that call lights should be accessible to residents to ensure they can call for assistance when needed. The facility's failure to provide accessible call lights for these residents is a deficiency in meeting their care needs.
Conflicting DNR Orders Lead to Unclear Code Status
Penalty
Summary
The facility failed to clarify the status of a resident's Do Not Resuscitate (DNR) order, leading to conflicting information regarding the resident's code status. The resident, who had no cognitive impairment and was dependent on all Activities of Daily Living (ADLs), had signed both the authorization to withhold life-saving measures and the revocation provision, indicating a desire for life-saving measures. This inconsistency was not addressed, resulting in confusion about the resident's wishes. Interviews with facility staff, including the MDS coordinator, Social Services Designee (SSD), Certified Nurses Aide (CNA), Licensed Practical Nurse (LPN), Registered Nurse (RN), and the Director of Nursing (DON), revealed that the resident's code status was documented in multiple places, including the electronic medical record, care plan, and a code status book at the nurses' station. However, the conflicting signatures on the DNR and the lack of clarity in the resident's medical record and care plan led to uncertainty among staff about the resident's actual code status. The SSD was responsible for ensuring the accuracy of DNRs, but the oversight resulted in a failure to provide clear and consistent documentation of the resident's wishes.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to meet professional standards of practice by not properly documenting the administration of medications for a resident. Specifically, the Medication Administration Record (MAR) for a resident showed missing entries for the administration of Gabapentin and Oxycodone on multiple occasions. The facility's policy requires that medications be administered by authorized staff and documented on the MAR, but there were blank spaces indicating a lack of documentation for these medications. Interviews with facility staff, including a Certified Medication Technician, a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing, confirmed that there should be no blank spaces on the MAR. They acknowledged that without documentation, it is unclear whether the medications were administered, refused, or unavailable. The resident involved reported severe pain and mentioned that the facility often runs out of pain medications, leading to periods without them.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in following physician orders and maintaining clean equipment. Resident #36, who has severe cognitive impairment and requires assistance with all activities of daily living, was not provided with continuous oxygen therapy as ordered by the physician. Observations revealed that the resident had no oxygen tank or concentrator in the room, and staff were unaware of the active oxygen order. Additionally, an unclean oxygen concentrator was found in the resident's room, indicating a lack of adherence to the facility's oxygen policy. Resident #13, diagnosed with dementia, congestive heart failure, and respiratory failure, also experienced deficiencies in respiratory care. The resident's care plan required continuous oxygen therapy while in bed, but observations showed a dirty oxygen concentrator with outdated tubing in the room. Interviews with staff revealed that housekeeping was responsible for cleaning the outside of the concentrators, but not the filters, and nursing staff were responsible for replacing and updating tubing dates. The facility's failure to follow physician orders and maintain clean oxygen equipment for these residents highlights a lack of compliance with professional standards of practice. Interviews with staff, including the Director of Nursing and the Administrator, confirmed that physician orders should be followed as written and that oxygen equipment should be cleaned before being provided to residents. These deficiencies affected two of the 18 sampled residents in a facility with a census of 82.
Resident Forcibly Fed Despite Refusal
Penalty
Summary
The facility failed to protect a resident from abuse when a staff member forcibly fed the resident despite the resident's refusal to eat. The incident involved a resident with no cognitive deficits, who was capable of feeding themselves and had no swallowing or chewing difficulties. The resident expressed distress and fear of choking during the incident, which was reported to the night nurse and later to the Director of Therapy. The staff member involved, a Certified Nurse Aide (CNA), admitted to assisting the resident with eating, believing the resident was too weak to feed themselves. The CNA acknowledged awareness of resident rights, including the right to refuse care, but did not perceive their actions as abusive. The CNA's actions were reported by the resident to multiple staff members, including a Physical Therapy Assistant and a Licensed Practical Nurse, who felt the incident constituted abuse and reported it to the Administrator. The Administrator, upon reviewing the incident, concluded that the staff member acted inappropriately but did not classify the incident as abuse. The Administrator assured the resident that they would not have to work with the CNA again. The facility's policies on abuse and resident rights emphasize the importance of respecting residents' choices and preventing mistreatment, which were not adhered to in this case.
Facility Fails to Address Leak and Mold in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment by not addressing a leak in a resident room and an adjacent utility room. This oversight led to water running into the room, forming a large puddle on the floor, and causing a mold-like substance to develop on the ceiling and walls. The room's left side wall was saturated, with peeling sheet rock and a bubbled appearance, and rainwater was entering through gaps in the window frame. Despite the presence of an electric bed plugged into the affected wall, the facility did not provide adequate signage to prevent access to the hazardous area. Interviews with staff revealed that the leak had been ongoing for at least two weeks, and the door to the room was kept shut to deter residents from entering. The facility's administrator and corporate nurse were unaware of the mold and the extent of the leak, and the contractor responsible for replacing the roof was not informed of the leak's impact on the building's interior. The contract for the new roof did not include repairs to the affected room and utility room, and the project was delayed pending payment.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged incident of potential physical abuse involving a resident within the required timeframe. The incident involved a resident who reported being force-fed by a Certified Nurse Aide (CNA) during an evening meal. The resident, who had no cognitive deficits and was capable of feeding themselves, expressed distress and reported the incident to a Licensed Practical Nurse (LPN) on the night of the occurrence. The LPN immediately informed the Administrator, who decided not to report the incident to the State Agency, considering it a customer service issue rather than abuse. The resident described the incident as being force-fed, with the CNA breaking a sandwich into pieces and pushing it into the resident's mouth despite their protests. The resident attempted to refuse the food, but the CNA persisted, leading the resident to chew and swallow to avoid choking. The resident later reported the incident to a Physical Therapy Assistant (PTA), who then informed their supervisor. The Administrator, upon reviewing the situation, concluded that the staff member acted inappropriately but did not classify the incident as abuse. The facility's policy mandates that all alleged violations involving abuse be reported to the state agency within two hours. However, the Administrator did not adhere to this policy, as they did not report the incident, believing it did not constitute abuse. This failure to report the alleged violation in a timely manner resulted in noncompliance with state law and federal requirements related to the protection of residents from mistreatment.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to follow its policy to maintain documentation and conduct a thorough investigation of an alleged violation of resident abuse. A resident reported being force-fed by a CNA, which was not properly investigated by the facility. The resident, who had no cognitive deficits and did not require assistance with eating, reported the incident to a night nurse, who then informed the Administrator. However, the Administrator did not immediately investigate the incident or obtain statements from the involved staff. The resident described the incident as being force-fed a sandwich by the CNA, despite expressing a desire not to eat. The CNA continued to push food into the resident's mouth, ignoring the resident's refusal. The resident reported feeling forced to eat to avoid choking. The facility's investigation was inadequate, as it did not include interviews with all involved parties or proper documentation of the incident. Interviews with staff revealed that the Administrator considered the issue a matter of customer service rather than abuse, and therefore did not conduct a full investigation. The facility's policy required immediate investigation and thorough documentation, which was not followed. The lack of a comprehensive investigation and failure to obtain necessary statements from staff members contributed to the deficiency.
Failure to Notify Physician of Antirejection Medication Refusal
Penalty
Summary
Facility staff failed to notify the physician when a resident with a history of liver transplant, dementia, Alzheimer's disease, and other significant diagnoses refused to take their prescribed tacrolimus, an antirejection medication, for two consecutive days. The resident also refused food and fluids over several days, with documentation showing 0% meal intake and medication refusals. Despite these refusals and the resident exhibiting signs of illness such as sunken eyes, dry mouth, and poor skin turgor, there was no documentation that the physician was notified about the missed doses of the antirejection medication. Interviews with staff revealed that it was not typical for this resident to refuse meals or medications, and that the nurse should have been notified immediately of the refusal, especially for critical medications like antirejection drugs. The primary care physician confirmed he was not informed about the missed doses, only that the resident was unwell, and stated he would have expected to be notified. Facility policies required staff to report and document medication refusals and to promptly notify the physician of significant changes, but these procedures were not followed in this case.
Failure to Maintain Safe and Homelike Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment in the memory care unit by not addressing multiple holes in the ceiling. Observations revealed a 24-inch square open hole in the hallway outside a resident's room, another 24-inch square open hole near the nurses' station, two 12-inch square holes covered with plastic sheeting, and five circular holes filled with plastic sheeting in the area leading from the nurses' station to the dining area. These deficiencies were noted during a survey on 3/20/24, and the facility did not provide a policy regarding maintaining the environment. Interviews with the Director of Maintenance and the Administrator confirmed awareness of the holes, which were created by contractors to access the attic for pipe repairs after a sprinkler system incident in mid-February. However, the Director of Maintenance was unaware of some of the smaller holes, and both the Director and the Administrator were unsure when the contractors would return to complete the ceiling repairs. The facility census was 82, with 22 residents residing in the memory care unit affected by these conditions.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Saint Joseph
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Living Community Of St Joseph | 1.8 mi | ★★★★★ | 0 | 0 |
| St Joseph Manor Health & Rehabilitation | 2.6 mi | ★★★★★ | 2 | 0 |
| Carriage Square Rehab And Healthcare Center | 3 mi | ★★★★★ | 5 | 0 |
| St Joseph Chateau | 4.3 mi | ★★★★★ | 2 | 0 |
| Advanced Care Of St Joseph | 4.5 mi | ★★★★★ | 2 | 0 |
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