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Deficiency Records for Belle Care Nursing and Rehabilitation Center
A list of the most recent deficiencies for Belle Care 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 Belle Care 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 | 2024-06-26 | 2024-09-18 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-06-26 | 2024-09-18 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-06-26 | 2024-09-18 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2024-06-26 | 2024-09-18 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-06-26 | 2024-09-18 | N |
| Provide activities to meet all resident's needs. | Health | 2024-06-26 | 2024-09-18 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-06-26 | 2024-09-18 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-06-26 | 2024-08-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-26 | 2024-08-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-26 | 2024-08-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-26 | 2024-08-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-06-26 | 2024-08-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-26 | 2024-08-30 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-06-26 | 2024-08-30 | 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 | 2024-06-26 | 2024-08-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-06-26 | 2024-08-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-26 | 2024-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-26 | 2024-08-30 | 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 | 2024-06-26 | 2024-08-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-26 | 2024-08-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-26 | 2024-08-30 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-06-26 | 2024-08-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-26 | 2024-08-30 | 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 | 2024-06-26 | 2024-08-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-06-26 | 2024-08-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-26 | 2024-08-30 | 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 | 2024-06-26 | 2024-08-30 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-06-26 | 2024-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-26 | 2024-08-30 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-06-26 | 2024-08-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-06-26 | 2024-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-26 | 2024-08-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-06-26 | 2024-08-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-06-26 | 2024-08-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-06-26 | 2024-08-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-26 | 2024-08-30 | 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 | 2024-06-26 | 2024-08-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-06-26 | 2024-08-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-06-26 | 2024-08-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-06-26 | 2024-08-30 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-06-26 | 2024-08-30 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-06-26 | 2024-08-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-06-26 | 2024-08-25 | 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 | 2024-06-26 | 2024-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-26 | 2024-08-25 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-06-26 | 2024-08-25 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-06-26 | 2024-08-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-26 | 2024-08-25 | 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 | 2022-10-20 | 2022-12-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-10-20 | 2022-12-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-10-20 | 2022-12-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-10-20 | 2022-12-05 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-20 | 2022-12-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-10-20 | 2022-12-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-20 | 2022-12-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-10-20 | 2022-12-05 | 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 | 2022-10-20 | 2022-12-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-20 | 2022-12-05 | 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 | 2022-10-20 | 2022-12-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-20 | 2022-12-05 | 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 | 2022-10-20 | 2022-12-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-20 | 2022-12-05 | 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 | 2022-10-20 | 2022-12-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-20 | 2022-12-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-10-20 | 2022-12-05 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-10-20 | 2022-12-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-10-20 | 2022-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-20 | 2022-12-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-10-20 | 2022-12-05 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-10-20 | 2022-12-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-20 | 2022-11-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-10-20 | 2022-11-10 | 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 | 2022-10-20 | 2022-11-10 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-10-20 | 2022-11-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-20 | 2022-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-21 | 2020-11-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-21 | 2020-11-05 | N |
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