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Deficiency Records for Bella Terra St George

A list of the most recent deficiencies for Bella Terra St George. 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 Bella Terra St George. 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?
Conduct testing and exercise requirements. Fire Safety 2023-06-28 2023-08-22 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 2023-06-28 2023-08-22 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-06-28 2023-08-22 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-06-28 2023-08-19 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-06-28 2023-08-19 N
Have exits that are accessible at all times. Fire Safety 2023-06-28 2023-08-06 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-06-28 2023-08-04 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2023-06-28 2023-07-31 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-06-28 2023-07-31 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-06-28 2023-07-31 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 2023-06-28 2023-07-31 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2023-06-28 2023-07-31 Y
Implement a program that monitors antibiotic use. Health 2023-06-28 2023-07-31 Y
Have simulated fire drills held at unexpected times. Fire Safety 2023-06-28 2023-07-12 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-01-26 2023-03-29 Y
Respond appropriately to all alleged violations. Health 2023-01-26 2023-03-29 Y
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 2022-03-08 2022-05-18 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-03-08 2022-05-18 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-09-16 2021-12-06 N
Reasonably accommodate the needs and preferences of each resident. Health 2021-09-16 2021-12-06 N
Honor the resident's right to manage his or her financial affairs. Health 2021-09-16 2021-12-06 N
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2021-09-16 2021-12-06 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-09-16 2021-12-06 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2021-09-16 2021-12-06 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 2021-09-16 2021-12-06 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 2021-09-16 2021-12-06 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2021-09-16 2021-12-06 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2021-09-16 2021-12-06 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2021-09-16 2021-12-06 N
Ensure each resident receives an accurate assessment. Health 2021-09-16 2021-12-06 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-09-16 2021-12-06 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2021-09-16 2021-12-06 N
Provide activities to meet all resident's needs. Health 2021-09-16 2021-12-06 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 2021-09-16 2021-12-06 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 2021-09-16 2021-12-06 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-09-16 2021-12-06 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 2021-09-16 2021-12-06 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Health 2021-09-16 2021-12-06 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 2021-09-16 2021-12-06 N
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2021-09-16 2021-12-06 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 2021-09-16 2021-12-06 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2021-09-16 2021-12-06 N
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 2021-09-16 2021-12-06 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-09-16 2021-12-06 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-09-16 2021-12-06 N
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Health 2021-09-16 2021-12-06 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-09-16 2021-12-06 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2021-09-16 2021-12-06 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2021-09-16 2021-12-06 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2021-09-16 2021-12-06 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2021-09-16 2021-12-06 N
Provide and implement an infection prevention and control program. Health 2021-09-16 2021-12-06 N
Perform COVID19 testing on residents and staff. Health 2021-09-16 2021-12-06 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 2021-09-16 2021-12-06 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-09-16 2021-11-15 N
Meet other general requirements. Fire Safety 2021-09-16 2021-11-15 N
Have exits that are accessible at all times. Fire Safety 2021-09-16 2021-11-15 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-09-16 2021-11-15 N
Meet requirements for the use of electrical equipment. Fire Safety 2021-09-16 2021-11-15 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2019-11-20 2020-01-15 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2019-11-20 2020-01-15 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2019-11-20 2020-01-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-11-20 2020-01-15 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-11-20 2020-01-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-11-20 2020-01-15 N
Not hire anyone with a finding of abuse, neglect, exploitation, or theft. Health 2019-11-21 2020-01-07 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2019-11-21 2020-01-07 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-11-21 2020-01-07 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 2019-11-21 2020-01-07 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-11-21 2020-01-07 N
Provide enough food/fluids to maintain a resident's health. Health 2019-11-21 2020-01-07 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 2019-11-21 2020-01-07 N
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Health 2019-11-21 2020-01-07 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Health 2019-11-21 2020-01-07 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2019-11-21 2020-01-07 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 2019-11-21 2020-01-07 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 2019-11-21 2020-01-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-11-21 2020-01-07 N
Provide and implement an infection prevention and control program. Health 2019-11-21 2020-01-07 N

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