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Deficiency Records for Belmont Healthcare Center
A list of the most recent deficiencies for Belmont Healthcare 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 Healthcare 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2024-06-18 | 2024-06-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-18 | 2024-06-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-06-18 | 2024-06-27 | Y |
| 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 | 2024-06-18 | 2024-06-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-01 | 2023-08-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-01 | 2023-08-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-08-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-01 | 2023-08-09 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-06-01 | 2023-08-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-14 | 2023-08-01 | Y |
| 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 | 2021-11-19 | 2022-01-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-19 | 2022-01-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-19 | 2022-01-04 | 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 | 2021-11-19 | 2022-01-04 | 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 | 2021-11-19 | 2022-01-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-11-19 | 2022-01-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-19 | 2022-01-04 | 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 | 2021-11-19 | 2022-01-04 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-11-19 | 2022-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-19 | 2022-01-04 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-11-19 | 2022-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2022-01-04 | N |
| Keep all essential equipment working safely. | Health | 2021-11-19 | 2022-01-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-23 | 2021-12-23 | 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 | 2021-11-23 | 2021-12-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-23 | 2021-12-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-23 | 2021-12-23 | 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 | 2019-06-07 | 2019-10-11 | 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 | 2019-06-07 | 2019-10-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-06-07 | 2019-10-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-07 | 2019-10-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-07 | 2019-08-27 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-06-07 | 2019-08-16 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-06-07 | 2019-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-07 | 2019-08-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-07 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-07 | 2019-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-07 | 2019-08-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-07 | 2019-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-07 | 2019-08-16 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-06-07 | 2019-08-16 | N |
| Post nurse staffing information every day. | Health | 2019-06-07 | 2019-08-16 | 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 | 2019-06-07 | 2019-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-07 | 2019-08-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-06-07 | 2019-08-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-24 | 2018-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-24 | 2018-12-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-07-24 | 2018-12-27 | 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 | 2018-07-24 | 2018-12-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-07-24 | 2018-11-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-24 | 2018-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-24 | 2018-11-05 | 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 | 2018-07-24 | 2018-11-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-07-24 | 2018-11-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-07-24 | 2018-11-05 | 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 | 2018-07-24 | 2018-11-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-24 | 2018-11-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-07-24 | 2018-11-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-07-24 | 2018-11-05 | 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 | 2018-07-24 | 2018-11-05 | 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 | 2018-07-24 | 2018-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-24 | 2018-11-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-07-24 | 2018-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-24 | 2018-11-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-07-24 | 2018-11-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-17 | 2018-10-30 | N |
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