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Deficiency Records for Belmont Terrace
A list of the most recent deficiencies for Belmont Terrace. 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. 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 | 2024-01-05 | 2024-02-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-05 | 2024-02-27 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-05 | 2024-02-27 | Y |
| 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 | 2024-01-05 | 2024-02-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-13 | 2023-11-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-13 | 2023-11-27 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-10-13 | 2023-11-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-13 | 2023-11-27 | 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 | 2023-10-13 | 2023-11-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-13 | 2023-11-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-13 | 2023-11-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-13 | 2023-11-27 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-13 | 2023-11-27 | 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 | 2023-10-13 | 2023-11-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-13 | 2023-11-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-13 | 2023-11-27 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-13 | 2023-11-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-13 | 2023-11-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-11-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-11 | 2023-11-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-11 | 2023-11-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-10-11 | 2023-11-10 | 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 | 2023-08-25 | 2023-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-09 | 2023-06-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-10 | 2023-04-26 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-11-29 | 2023-01-06 | N |
| Protect a residents' right to refuse some types of non-requested transfers within the nursing home. | Health | 2022-11-29 | 2023-01-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-29 | 2023-01-06 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-11-29 | 2023-01-06 | 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 | 2022-11-29 | 2023-01-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-29 | 2023-01-06 | 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 | 2022-11-29 | 2023-01-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-29 | 2023-01-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-11-29 | 2023-01-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-29 | 2023-01-06 | 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 | 2022-11-29 | 2023-01-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-29 | 2023-01-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-29 | 2023-01-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-29 | 2023-01-06 | 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 | 2022-11-29 | 2023-01-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-29 | 2023-01-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-29 | 2023-01-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-29 | 2023-01-06 | 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 | 2022-11-29 | 2023-01-06 | 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 | 2022-11-29 | 2023-01-06 | 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 | 2022-11-29 | 2023-01-06 | 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 | 2022-11-29 | 2023-01-06 | N |
| Provide or obtain dental services for each resident. | Health | 2022-11-29 | 2023-01-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-29 | 2023-01-06 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-11-29 | 2023-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-29 | 2023-01-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-29 | 2023-01-06 | 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 | 2022-11-29 | 2023-01-06 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-29 | 2023-01-06 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-29 | 2023-01-06 | Y |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-11-16 | 2022-12-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-16 | 2022-12-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-16 | 2022-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-16 | 2022-12-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-16 | 2022-12-01 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-10-26 | 2022-11-26 | Y |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-11-16 | 2022-11-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-27 | 2022-07-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-27 | 2022-07-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-26 | 2022-02-25 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-02-14 | 2020-03-29 | 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 | 2020-02-14 | 2020-03-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-14 | 2020-03-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-14 | 2020-03-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-14 | 2020-03-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-14 | 2020-03-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-14 | 2020-03-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-14 | 2020-03-29 | N |
| Post nurse staffing information every day. | Health | 2020-02-14 | 2020-03-29 | 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 | 2020-02-14 | 2020-03-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-14 | 2020-03-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-14 | 2020-03-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-13 | 2020-02-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-13 | 2020-02-21 | N |
| Have an externally vented heating system. | Fire Safety | 2020-02-13 | 2020-02-14 | N |
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