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Deficiency Records for Belhaven Nursing and Rehab Center
A list of the most recent deficiencies for Belhaven Nursing and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Belhaven Nursing and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-30 | 2024-10-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-30 | 2024-10-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-09-30 | 2024-10-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-29 | 2024-09-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-12 | 2024-07-25 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-05-29 | 2024-06-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-25 | 2024-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-25 | 2024-04-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-01 | 2024-03-15 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2024-03-01 | 2024-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-19 | 2024-02-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-19 | 2024-02-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-07 | 2023-12-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-07 | 2023-12-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-07 | 2023-12-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-07 | 2023-12-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-03 | 2023-11-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-03 | 2023-11-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-11-03 | 2023-11-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-03 | 2023-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-03 | 2023-11-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-03 | 2023-11-17 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-11-03 | 2023-11-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-03 | 2023-11-17 | N |
| 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. | Health | 2023-11-03 | 2023-11-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-03 | 2023-11-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-03 | 2023-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-03 | 2023-11-17 | N |
| Dispose of garbage and refuse properly. | Health | 2023-11-03 | 2023-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-03 | 2023-11-17 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-11-03 | 2023-11-17 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-03 | 2023-11-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-05 | 2023-10-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-05 | 2023-10-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-05 | 2023-10-19 | Y |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2023-10-05 | 2023-10-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-05 | 2023-10-19 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-06-22 | 2023-06-30 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-22 | 2023-06-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-07 | 2023-05-15 | Y |
| 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. | Health | 2023-02-21 | 2023-03-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-21 | 2023-03-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-21 | 2023-03-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-21 | 2023-03-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-08 | 2022-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2022-12-29 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-12-08 | 2022-12-29 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-12-08 | 2022-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-08 | 2022-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2022-12-28 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-08 | 2022-12-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-08 | 2022-12-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-06 | 2022-10-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-06 | 2022-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-06 | 2022-10-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-26 | 2022-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-28 | 2022-08-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-24 | 2022-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-24 | 2022-07-20 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-24 | 2022-07-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-24 | 2022-07-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-24 | 2022-07-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-24 | 2022-07-20 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-09 | 2022-04-11 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-09 | 2022-04-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-24 | 2022-04-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-21 | 2022-03-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-07 | 2022-03-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-09 | 2022-03-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-09 | 2022-03-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-09 | 2022-03-06 | N |
| 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. | Health | 2022-02-09 | 2022-03-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-09 | 2022-03-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-09 | 2022-03-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-09 | 2022-03-06 | N |
| 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. | Health | 2022-02-09 | 2022-03-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-09 | 2022-03-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-09 | 2022-03-06 | N |
| 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. | Health | 2022-02-09 | 2022-03-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-03-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-09 | 2022-03-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-09 | 2022-03-06 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-02-09 | 2022-03-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-09 | 2022-03-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-12-13 | 2021-12-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-13 | 2021-12-30 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-13 | 2021-12-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-13 | 2021-12-30 | Y |
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