Deficiency Records for Belhaven Nursing and Rehab Center
Updated as of March 01, 2023
This is not the most recent data for Belhaven Nursing and Rehab Center. For the most recent information, click here.
A list of the most recent deficiencies for Belhaven Nursing and Rehab 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-28 | 2023-02-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-28 | 2023-02-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-12-28 | 2023-01-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-28 | 2023-01-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-28 | 2023-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-28 | 2023-01-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-28 | 2023-01-20 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2022-12-28 | 2023-01-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-28 | 2023-01-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-28 | 2023-01-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-12-28 | 2023-01-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-28 | 2023-01-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-28 | 2023-01-11 | N |
| Meet other general requirements. | Fire Safety | 2022-12-28 | 2023-01-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-28 | 2023-01-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-12-28 | 2023-01-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-28 | 2023-01-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-28 | 2023-01-11 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-12-28 | 2023-01-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-28 | 2023-01-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-12-28 | 2023-01-03 | 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 | 2022-12-28 | 2023-01-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-28 | 2023-01-03 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-12-28 | 2023-01-03 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-12-28 | 2023-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-28 | 2023-01-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-08 | 2022-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2022-12-29 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-12-08 | 2022-12-29 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-12-08 | 2022-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-08 | 2022-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2022-12-28 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-08 | 2022-12-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-08 | 2022-12-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-06 | 2022-10-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-06 | 2022-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-06 | 2022-10-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-26 | 2022-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-28 | 2022-08-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-24 | 2022-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-24 | 2022-07-20 | 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 | 2022-06-24 | 2022-07-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-24 | 2022-07-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-24 | 2022-07-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-24 | 2022-07-20 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-09 | 2022-04-11 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-09 | 2022-04-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-24 | 2022-04-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-21 | 2022-03-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-07 | 2022-03-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-09 | 2022-03-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-09 | 2022-03-06 | 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 | 2022-02-09 | 2022-03-06 | 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 | 2022-02-09 | 2022-03-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-09 | 2022-03-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-09 | 2022-03-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-09 | 2022-03-06 | 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 | 2022-02-09 | 2022-03-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-09 | 2022-03-06 | 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 | 2022-02-09 | 2022-03-06 | 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 | 2022-02-09 | 2022-03-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-09 | 2022-03-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-09 | 2022-03-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-09 | 2022-03-06 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-02-09 | 2022-03-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-09 | 2022-03-06 | 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 | 2021-12-13 | 2021-12-30 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-13 | 2021-12-30 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-13 | 2021-12-30 | 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 | 2021-12-13 | 2021-12-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-13 | 2021-12-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-13 | 2021-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-21 | 2021-11-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-21 | 2021-11-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-21 | 2021-11-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-09 | 2021-07-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-09 | 2021-07-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-09 | 2021-07-23 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-05-07 | 2021-05-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-07 | 2021-05-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-07 | 2021-05-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-07 | 2021-05-27 | 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 | 2021-05-07 | 2021-05-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-07 | 2021-05-27 | 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 | 2021-05-07 | 2021-05-27 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-05-07 | 2021-05-27 | 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 | 2021-05-07 | 2021-05-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-07 | 2021-05-27 | 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 | 2021-05-07 | 2021-05-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-07 | 2021-05-27 | 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 | 2021-05-07 | 2021-05-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-07 | 2021-05-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-07 | 2021-05-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-07 | 2021-05-27 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-05-04 | 2021-05-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-04 | 2021-05-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-04 | 2021-05-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-04 | 2021-05-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-04 | 2021-05-25 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-05-04 | 2021-05-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-04 | 2021-05-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-15 | 2021-03-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-02 | 2021-03-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-02-01 | 2021-03-10 | 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 | 2021-02-01 | 2021-02-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-01-19 | 2021-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-31 | 2021-01-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-09-25 | 2020-10-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-09-25 | 2020-10-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-25 | 2020-10-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-05-20 | 2020-06-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2020-03-12 | 2020-04-03 | Y |
