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Health Inspection Summary

Belvedere Nursing and Rehabilitation Center, LLC

2600 Park Ave

Hot Springs, AR 71901

(501) 321-4276

Deficiency Category	Inspection Date: 11/7/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 12/21/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 9/28/22 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	0	2
Quality of Life and Care Deficiencies	1	2	4
Infection Control Deficiencies	1	2	1
Resident Assessment and Care Planning Deficiencies	1	4	3
Nursing and Physician Services Deficiencies	0	0	0
Resident Rights Deficiencies	0	1	0
Nutrition and Dietary Deficiencies	1	0	2
Pharmacy Service Deficiencies	0	1	1
Environmental Deficiencies	0	0	0
Administration Deficiencies	0	1	0

Detailed result for inspection on 11/7/24

Date of last standard health inspection:	11/7/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	4
Average number of Health Deficiencies in Arkansas:	7.5
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	11/7/24	12/7/24	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	11/7/24	12/7/24	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	11/7/24	12/7/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	11/7/24	12/7/24	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 12/21/23

Date of last standard health inspection:	12/21/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	10/13/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	11
Average number of Health Deficiencies in Arkansas:	8.2
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/21/23	1/4/24	3 - Actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	12/21/23	1/4/24	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	12/21/23	1/4/24	2 - Minimal harm or potential for actual harm	Some
Provide and implement an infection prevention and control program.	10/13/23	12/7/23	4 - Immediate jeopardy to resident health or safety	Many

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Assure that each resident’s assessment is updated at least once every 3 months.	12/21/23	1/4/24	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	12/21/23	1/4/24	2 - Minimal harm or potential for actual harm	Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	12/21/23	1/4/24	2 - Minimal harm or potential for actual harm	Some
Assess the resident when there is a significant change in condition	12/21/23	1/4/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	12/21/23	1/4/24	2 - Minimal harm or potential for actual harm	Some

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	12/21/23	1/4/24	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Have a plan that describes the process for conducting QAPI and QAA activities.	12/21/23	1/4/24	2 - Minimal harm or potential for actual harm	Some

Detailed result for inspection on 9/28/22

Date of last standard health inspection:	9/28/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	11/30/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	13
Average number of Health Deficiencies in Arkansas:	8.5
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	11/30/22	12/30/22	2 - Minimal harm or potential for actual harm	Some
Respond appropriately to all alleged violations.	11/30/22	12/30/22	2 - Minimal harm or potential for actual harm	Some

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	11/30/22	12/30/22	3 - Actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/28/22	10/10/22	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	9/28/22	10/10/22	2 - Minimal harm or potential for actual harm	Some
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	9/28/22	10/10/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	11/30/22	12/30/22	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	9/28/22	10/10/22	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	9/28/22	10/10/22	2 - Minimal harm or potential for actual harm	Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	9/28/22	10/10/22	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.	9/28/22	10/10/22	2 - Minimal harm or potential for actual harm	Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	9/28/22	10/10/22	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	9/28/22	10/10/22	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	10/13/23	12/7/23	4 - Immediate jeopardy to resident health or safety	Many
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	11/30/22	12/30/22	2 - Minimal harm or potential for actual harm	Some
Respond appropriately to all alleged violations.	11/30/22	12/30/22	2 - Minimal harm or potential for actual harm	Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	11/30/22	12/30/22	3 - Actual harm	Few
Provide and implement an infection prevention and control program.	11/30/22	12/30/22	2 - Minimal harm or potential for actual harm	Some

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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