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Health Inspection Summary

Belvidere Healthcare Center

500 Wentworth Avenue

Lowell, MA 01852

(978) 458-1271

Deficiency Category	Inspection Date: 5/16/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 3/24/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 4/14/22 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	4	2	1
Quality of Life and Care Deficiencies	5	8	4
Infection Control Deficiencies	0	1	1
Resident Assessment and Care Planning Deficiencies	2	1	4
Nursing and Physician Services Deficiencies	0	2	0
Resident Rights Deficiencies	1	4	1
Nutrition and Dietary Deficiencies	3	5	2
Pharmacy Service Deficiencies	1	2	3
Environmental Deficiencies	0	1	0
Administration Deficiencies	0	1	1

Detailed result for inspection on 5/16/24

Date of last standard health inspection:	5/16/24Read 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:	16
Average number of Health Deficiencies in Massachusetts:	10
Average number of Health Deficiencies in the United States:	9.6

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.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few

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)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few
Assist a resident in gaining access to vision and hearing services.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few
Provide enough food/fluids to maintain a resident's health.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

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.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	5/16/24	6/15/24	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.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few

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 food and drink is palatable, attractive, and at a safe and appetizing temperature.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.	5/16/24	6/15/24	2 - Minimal harm or potential for actual harm	Few

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.	5/16/24	6/15/24	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.

Detailed result for inspection on 3/24/23

Date of last standard health inspection:	3/24/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	11/29/23Read 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:	27
Average number of Health Deficiencies in Massachusetts:	12
Average number of Health Deficiencies in the United States:	9.4

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.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few

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)
Provide care and assistance to perform activities of daily living for any resident who is unable.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	3/24/23	4/25/23	3 - Actual harm	Few
Provide or obtain dental services for each resident.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Some
Provide safe and appropriate respiratory care for a resident when needed.	3/24/23	5/11/23	2 - Minimal harm or potential for actual harm	Few
Provide safe, appropriate pain management for a resident who requires such services.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	11/29/23	12/21/23	3 - Actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	3/24/23	4/25/23	3 - Actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	3/24/23	4/25/23	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.	3/24/23	4/25/23	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 services provided by the nursing facility meet professional standards of quality.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services 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)
Observe each nurse aide's job performance and give regular training.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Some
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Some

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 voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to organize and participate in resident/family groups in the facility.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Some

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.	3/24/23	5/11/23	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.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few

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 medication error rates are not 5 percent or greater.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Some
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Few

Environmental 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)
Keep all essential equipment working safely.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Many

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)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	3/24/23	4/25/23	2 - Minimal harm or potential for actual harm	Many

Detailed result for inspection on 4/14/22

Date of last standard health inspection:	4/14/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	11/23/22Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	17
Average number of Health Deficiencies in Massachusetts:	11
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)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	4/14/22	5/26/22	2 - Minimal harm or potential for actual harm	Few

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)
Provide care and assistance to perform activities of daily living for any resident who is unable.	4/14/22	6/1/22	2 - Minimal harm or potential for actual harm	Few
Provide enough food/fluids to maintain a resident's health.	4/14/22	5/26/22	3 - Actual harm	Few
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	4/14/22	5/26/22	3 - Actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	4/14/22	5/26/22	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.	4/14/22	5/26/22	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.	4/14/22	6/1/22	2 - Minimal harm or potential for actual harm	Some
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	4/14/22	5/26/22	2 - Minimal harm or potential for actual harm	Some
Ensure each resident receives an accurate assessment.	4/14/22	5/26/22	2 - Minimal harm or potential for actual harm	Few
Assess the resident when there is a significant change in condition	4/14/22	6/1/22	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
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep residents' personal and medical records private and confidential.	4/14/22	5/26/22	2 - Minimal harm or potential for actual harm	Few

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 food and drink is palatable, attractive, and at a safe and appetizing temperature.	4/14/22	5/26/22	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.	4/14/22	6/1/22	2 - Minimal harm or potential for actual harm	Few

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)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	4/14/22	5/26/22	2 - Minimal harm or potential for actual harm	Few
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.	4/14/22	5/26/22	2 - Minimal harm or potential for actual harm	Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	4/14/22	5/26/22	2 - Minimal harm or potential for actual harm	Few

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)
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.	4/14/22	5/26/22	2 - Minimal harm or potential for actual harm	Few

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)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	11/29/23	12/21/23	3 - Actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years.

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