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Deficiency Records for Belmont Terrace Nursing and Rehabilitation Center
A list of the most recent deficiencies for Belmont Terrace Nursing and Rehabilitation 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 Belmont Terrace Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-08 | 2024-06-05 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-03-08 | 2024-06-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-03-08 | 2024-06-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-08 | 2024-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-08 | 2024-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-08 | 2024-06-05 | 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 | 2024-03-08 | 2024-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-08 | 2024-05-01 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-03-08 | 2024-04-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-08 | 2024-04-30 | 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 | 2024-03-08 | 2024-04-30 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2024-03-08 | 2024-04-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-08 | 2024-04-30 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-08 | 2024-04-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-08 | 2024-04-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-08 | 2024-04-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-08 | 2024-04-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-08 | 2024-04-30 | 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 | 2024-03-08 | 2024-04-30 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-03-08 | 2024-04-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-03-08 | 2024-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-08 | 2024-04-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-03-08 | 2024-04-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-08 | 2024-04-30 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-03-08 | 2024-04-30 | 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 | 2024-03-08 | 2024-04-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-08 | 2024-04-30 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-03-08 | 2024-04-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-08 | 2024-04-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-08 | 2024-04-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-08 | 2024-04-30 | Y |
| 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. | Health | 2024-03-08 | 2024-04-30 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-28 | 2024-04-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-14 | 2021-06-24 | 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 | 2021-05-14 | 2021-06-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-14 | 2021-06-24 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-05-14 | 2021-06-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-14 | 2021-06-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-14 | 2021-06-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-14 | 2021-06-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-14 | 2021-06-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-14 | 2021-06-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-14 | 2021-06-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-14 | 2021-06-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-14 | 2021-06-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-14 | 2021-06-24 | 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 | 2021-05-14 | 2021-06-24 | 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 | 2021-05-14 | 2021-06-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-14 | 2021-06-24 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-05-14 | 2021-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-14 | 2021-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-21 | 2021-06-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-21 | 2021-06-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-04-21 | 2021-06-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-21 | 2021-06-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-03 | 2019-06-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-03 | 2019-06-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-03 | 2019-06-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-03 | 2019-06-12 | 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 | 2019-05-03 | 2019-06-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-03 | 2019-06-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-03 | 2019-06-12 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-05-03 | 2019-06-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-03 | 2019-06-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-05-03 | 2019-06-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-03 | 2019-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-30 | 2019-06-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-30 | 2019-06-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-30 | 2019-06-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-30 | 2019-06-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-30 | 2019-06-12 | N |
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