Gardens Care Homes - Belmar Acres, the

A licensure survey revisit was completed on 6/25/25 for the previous deficiencies cited on 9/21/22. A deficiency was cited. Tag T1596 was not cited in the previous event; however, the deficiencies were included in the previous event' s informational 999 tag. Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting three residents (#2, #9, #10) whose medications were administered. Findings include:The residence' s Procedure For Infection Control In The Residential Care Setting dated June 2000, read in part, "proper hand washing with soap, water, and friction is absolutely essential in preventing the spread of infection ... Hand washing is required between contact between each resident, after removing gloves, and before going on to another procedure or situation."On 6/24/25 from 7:36 a.m. to approximately 7.55 a.m., the following was observed: Staff #1 escorted Resident #10 to the restroom, where she administered artificial tear drops. Staff #1 then escorted Resident #10 to the common room, where Staff #1 was observed picking up a used tissue and throwing it away. Staff #1 proceeded to the kitchen, where she drank from a personal cup, then prepared food and drink, and served it to Resident #9. Staff #1 proceeded to the medication cart and prepared medications and administered them to Resident #9. Staff #1 returned to the medication cart and prepared crushed medications, mixed them in yogurt, and administered them to Former Resident #2. No hand hygiene was performed prior to or following medication administration. On 6/24/25 at 2:14 p.m., Staff #1 stated she got nervous and acknowledged that she did not perform hand hygiene before or after administering medications to Former Resident #2 and Residents #9 and #10.On 6/25/25 at 12:13 p.m., the administrator stated that she expects the residence to follow the proper hand washing and infection control. Additionally, she acknowledged it is essential in preventing the spread of flu, colds, and norovirus.

A relicensure survey was completed on 6/25/25. Deficiencies were cited. A change of ownership occurred on 6/25/25. Based on observation and interview, the residence failed to ensure all medications were stored in a locked storage area when unattended by a qualified medication administration person (QMAP) or other licensed staff, affecting 10 current residents. Findings include:The residence' s Medication and Medication Administration police read in part "all prescription and non-prescription medication must be maintained and stored in a manner that ensures the safety of all residents or clients" and "all medications are stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed staff".On 6/24/25 at 7:12 a.m., Staff #1 unlocked the staff office door to allow access. In the staff office was a blister pack containing 24 oxycodone 10 mg tablets prescribed to Resident #2 on the desk. On 6/24/25 from 7:22 a.m. to 7:31 a.m., the staff office door, which residents walk past, was observed open, unlocked, and unattended. Additionally, a resident was observed standing near the do.. Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting three residents (#2, #9, #10) whose medications were administered. Findings include:The residence' s Procedure For Infection Control In The Residential Care Setting dated June 2000, read in part, "proper hand washing with soap, water, and friction is absolutely essential in preventing the spread of infection ... Hand washing is required between contact between each resident, after removing gloves, and before going on to another procedure or situation."On 6/24/25 from 7:36 a.m. to approximately 7.55 a.m., the following was observed: Staff #1 escorted Resident #10 to the restroom, where she administered artificial tear drops. Staff #1 then escorted Resident #10 to the common room, where Staff #1 was observed picking up a used tissu.. Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents and their room assignments, affecting 78 current residents.The residence' s Emergency Policies And Procedures, dated June 2000, read in part, "the community has readily available a roster of current residents, their room assignments, and emergency contact information along with a building diagram showing room locations". On 6/24/25 at 7:06 a.m., the residence was asked to provide a resident roster. Staff #1 provided the residence emergency binder containing eight residents' face sheets and a facility diagram. However, there were currently 10 residents at the residence.A resident roster and facility diagram were observed posted in the staff office but were not current. On 6/24/25 at 7:06 a.m., Staff #1 stated that the current resident census was 10 residents.On 6/25/25 at 12:15 p.m., the administrator stated both she and Staff #1 were responsible for maintaining the resident emergency ..