Federal inspectors cited Belmont Terrace for medication management failures affecting three residents during a November complaint investigation.
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State regulations require facilities to report abuse allegations within 24 hours, or within two hours if serious bodily injury is involved.
The facility's wound care nurse discovered the mother had been changing the dressing on several occasions when she arrived after 6 PM.
The medication mistakes affected residents with chronic kidney disease and autism spectrum disorder.
Licensed Vocational Nurse A assessed the resident after the fall, helped transfer him from wheelchair to bed, and completed a head-to-toe examination.
The facility's Director of Nursing acknowledged the severity of the oversight during the November inspection.
Her care plan specifically outlined interventions to prevent injuries, including non-skid footwear and keeping her bed in the lowest position.
The same nurse later told inspectors that each medication should have been administered separately in case residents display adverse reactions and vomit.
Federal inspectors observed Unit Manager #2 performing what should have been routine care that morning at 8:14 AM.
Resident #1's family had to bring an ultraviolet insect trap to his room in August 2025 because of the ongoing insect problem.
The treatment began at Northern Riverview Health Care on August 30, 2025, after a family member reported that the resident's right eye appeared red.
Resident #6 was eating lunch on June 5, 2025, when they lifted the chicken from their plate and discovered mushrooms underneath.