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Deficiency Records for Belair Healthcare and Rehabilitation Center
A list of the most recent deficiencies for Belair Healthcare 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 Belair Healthcare 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? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-17 | 2024-07-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-17 | 2024-07-16 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-05-17 | 2024-07-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-05-17 | 2024-07-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-05-17 | 2024-07-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-17 | 2024-07-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-05-17 | 2024-07-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-17 | 2024-07-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-05-17 | 2024-07-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-17 | 2024-07-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-17 | 2024-07-16 | 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 | 2024-05-17 | 2024-07-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-17 | 2024-07-16 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-05-17 | 2024-07-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-05-17 | 2024-07-16 | 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 | 2024-05-17 | 2024-07-16 | 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 | 2024-05-17 | 2024-07-16 | 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 | 2024-05-17 | 2024-07-16 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-05-17 | 2024-07-16 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-05-17 | 2024-07-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-17 | 2024-07-16 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-05-17 | 2024-07-16 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-05-17 | 2024-07-16 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-05-17 | 2024-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-15 | 2024-05-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-15 | 2024-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-17 | 2024-05-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-20 | 2024-02-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-20 | 2024-02-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-09 | 2023-07-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-09 | 2023-07-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-09 | 2023-07-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-09 | 2023-07-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-09 | 2023-07-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-08 | 2023-07-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-08 | 2023-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-08 | 2023-07-11 | 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 | 2022-08-10 | 2022-10-01 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-06-10 | 2022-07-20 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-06-10 | 2022-07-20 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-10 | 2022-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-10 | 2022-07-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-10 | 2022-07-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-10 | 2022-07-20 | 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 | 2022-06-10 | 2022-07-20 | N |
| Report COVID19 data to residents and families. | Health | 2022-06-10 | 2022-07-20 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-10 | 2022-07-20 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-10 | 2022-07-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-10 | 2022-07-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-10 | 2022-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-10 | 2022-07-20 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-14 | 2022-07-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-04-25 | 2022-05-02 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-03-14 | 2022-04-14 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-03-14 | 2022-04-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-14 | 2022-04-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-14 | 2022-04-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-14 | 2022-04-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-14 | 2022-04-14 | 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 | 2022-03-14 | 2022-04-14 | Y |
| 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 | 2022-03-14 | 2022-04-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-14 | 2022-04-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-14 | 2022-03-10 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-14 | 2022-03-10 | Y |
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