Bel Aire Center

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

today and was unable to provide any information as to when s/he was switched from a Velcro belt to a buckle seat belt.Per interview on 10/14/25 at 1:35 PM, the Nurse Practitioner stated that Resident #2 used

a seat belt for fall prevention and was not cognitively able to remove the seat belt on command. The NP confirmed that Resident #2's buckle seat belt would be considered a restraint.Per phone interview on 10/15/25 at 3:17 PM, Resident #2's Representative explained that Resident #2 used to have a Velcro seat belt, but it was changed to a seat belt with a button after his/her last fall. The Representative doesn't remember the facility letting him/her know of the change or getting consent for that change but had noticed

a change after a visit with Resident #2 after their last fall. The Representative explained that the seat belt was used to prevent Resident #2 from falling.Per record review, Resident #2 does not have a physician order for a buckled seat belt that specifies a medical symptom, frequency of use and release time, and activities to be performed during release. Resident #2's care plan was updated on 9/30/25 to remove the use of a Velcro seat belt and change to seat belt. Resident #2's medical record, including their care plan, does not include documentation of how the use of the seat belt would treat a medical symptom that warrants the use of restraints, the type of direct monitoring and supervision that will be provided during use of the restraint, recommendations for gradual reduction, or address any risks related to the use of the restraint. The is no evidence that consent was obtained for the use of a buckle seat belt. There is no evidence of completed restraint assessments after the initial evaluation completed on 7/16/25.Per a virtual

interview on 10/17/25 at 9:30 AM, the DON was unable to determine who or when Resident #2's Velcro seat belt was changed to a buckle seat belt. The DON confirmed that the restraint policy was not followed for Resident #2 because his/her seat belt was not considered a restraint.Facility policy titled NSG233 Restraints: Use of, revised 9/15/25, reads, Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms . Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of restraints. Physical restraint refers to any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: Is attached or adjacent to the patient's body, Cannot be removed easily by the patient, and Restricts the patient's freedom of movement or normal access to their body.Removes Easily means that the manual method, physical or mechanical device, equipment, or material can be removed intentionally by the patient in the same manner as it was applied by staff.3.1 The Center will determine the presence of a specific medical symptom that would require the use of restraints and determine:3.1.1 How the use of restraints would treat the medical symptoms;3.1.2 The length of time

the restraint is anticipated to be used to treat the medical symptoms, who may apply the restraint, and the time and frequency that the restraint will be released;3.1.3 The type of direct monitoring and supervision that will be provided during use of the restraint;5. Obtain physician\advanced practice provider (APP) order specifying:5.1 Type of device;5.2 Specific medical symptom;5.3 Frequency of use and release time (NOTE: PRN orders are not acceptable);5.4 Activities to be performed during release.6. Patients with the restraint will be reassessed monthly for three months, then quarterly and with any significant change in condition or

in accordance with state regulations.8. Consent must be obtained prior to the application of the restraint.

The patient, or the patient representative if applicable, has the right to refuse the use of a restraint and may withdraw consent to use the restraint at anytime. Refusal must be documented in the medical record.10.

Develop a plan of care for the use of the restraint. The care plan should be updated accordingly to include

the development and implementation of interventions, recommendations for gradual reduction and address any risks related to the use of the restraint.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bel Aire Center

35 Bel-Aire Drive Newport, VT 05855

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm

up from wheelchair unassisted and was walking and fell. There was no new intervention to prevent falls created after this fall.Per a virtual interview on 10/17/25 at 9:30 AM, the DON confirmed that Resident #2's care plan was only updated to reflect a medical review after the 9/17/25 fall.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet