Bellgrade Estates Senior Living

The documentation issues cited from February 2025 occurred before the current Executive Director and Health Services Director assumed their roles. During that time, the community relied heavily on temporary and agency personnel, and many records from that period were incomplete. Upon assuming leadership, required medication documentation practices were reinforced and stabilized. Current physician orders and MARs for all residents were reviewed and corrected. Resident #1 was assessed with no adverse outcomes identified. A review of all other residents confirmed no additional concerns. Medication documentation responsibilities were reinforced with permanent, trained staff. Required MAR documentation standards, order verification procedures, refusal documentation, and ALIS workflow expectations were retrained and re-established. Training conducted by the Health Services Director and pharmacy partners was documented and filed. Shift-by-shift MAR review, end-of-shift documentation checks, Med Tech competency reviews, and consistent shift-to-shift communication were restored to expected standards. PCC and ALIS eMAR alerts assisted with identifying missed medications, refusals, and discrepancies. Although Staff A. was already reviewing and correcting MARs, these tasks were not consistently documented prior to system stabilization. Under current leadership, these required practices are now formalized and consistently documented. Licensed nurse oversight was stabilized with dedicated first-shift supervision provided by Staff A. and newly hired 2nd and 3rd shift supervisors onboarding. Workforce development was strengthened through PCA-to-CNA advancement. Daily MAR audits for 60 days, weekly audits for four months, monthly QAPI review, and Executive Director spot-checks. All findings reported quarterly to QAPI. All corrective actions were in place prior to July 25, 2025. Duopa documentation concerns occurred prior to current leadership during a period of inconsistent agency staffing. Required documentation expectations were not consistently followed. After review, staff confirmed the resident self-administered the medication while staff stored and delivered cassettes. The resident is no longer in the community. A full resident review found no similar issues. All required documentation standards for self-administered medications, refrigerated medications, and ALIS entries were reinforced. Staff received refresher training from pharmacy and the Health Services Director, with documentation filed. Refrigerated medication procedures, order verification, ALIS accuracy checks, and documentation practices were restored to consistent use. PCC/ALIS alerts now provide real-time oversight for missed or late medication entries. While HSD was already identifying issues through these systems, daily documentation of these checks was formalized with the use of eMAR under current leadership. Permanent clinical staffing replaced prior agency-heavy operations. CNA advancement strengthened long-term compliance. Daily ALIS checks for 60 days, weekly audits for 4 months, monthly QAPI review, and Executive Director spot checks. Quarterly QAPI reporting.

The incident occurred prior to current leadership. Documentation confirming whether the report was submitted could not be located. The resident is no longer in the community. A review of all other resident files found no unreported incidents. The incident occurred prior to current leadership. Documentation confirming . Incident reporting processes were reviewed and updated. Staff were instructed on timely reporting requirements. Only permanent trained staff now submit reportable incidents. A standardized incident reporting procedure and 24-hour licensing notification checklist were created. A central incident tracking system in ALIS and binder format was implemented. Supervisory staffing stabilized. Training on incident reporting standards, documentation expectations, and the 24-hour requirement was conducted by the Executive Director. Attendance was documented and filed. Daily incident review for 60 days. Weekly audits for four months. Monthly QAPI evaluation. Executive Director and Health Services Director spot checks. Quarterly reporting to QAPI. All corrective actions were in place prior to July 25, 2025, with ongoing monitoring as outlined in this Plan of Correction.

The events occurred prior to current leadership during a time of incomplete and inconsistent documentation. Required supervisory processes were re-established under new leadership. A full resident review showed no additional concerns. Care plan clarity expectations, documentation standards, COCO reporting, and shift communication responsibilities were reinforced. Required training on COCO procedures, nurse notification, PCC/ALIS documentation, and shift communication was established in June 2025 by the Health Services Director. Attendance was documented and filed. Daily clinical rounds, COCO documentation, supervisory communication protocols, and consistent oversight--often performed but undocumented previously-were formalized into structured processes. PCC/ALIS tools assisted with real-time alerts for changes in condition. Permanent clinical staffing replaced agency usage. CNA advancement supports sustained compliance. Daily COCO review for 60 days, weekly audits for 4 months, twice-monthly ED checks, monthly QAPI review, quarterly QAPI reporting All corrective actions were in place prior to July 25, 2025, with ongoing monitoring as outlined in this Plan of Correction.

All buildings will be well-ventilated and free from foul, stale, and musty odors. The facility maintenance director with housekeeping staff will round daily and report out concerns with odor to the executive director who will deploy resources to diagnose and neutralize the source. Monthly safety meetings run by the Executive Director will review patterns with reporting of maintenance issues and utilize quality assessment and performance improvement project tracking to deploy preventative measures.

The rights and responsibilities of residents at Morningside of Bellgrade will be reviewed annually with each resident or his legal representative or responsible individual as well as staff. Documentation of the review will include the date of review and occur as stipulated in subsection H of the cited regulation. The Executive Director will be responsible for performing and documentation of the review with each resident. Annual business file audits will be used to ensure compliance.