Deficiency Records for Belltower Health and Rehabilitation Center
Updated as of August 01, 2022
This is not the most recent data for Belltower Health and Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Belltower Health 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-03-09 | 2022-04-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-09 | 2022-04-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-13 | 2022-01-05 | Y |
| 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 | 2021-12-13 | 2022-01-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-13 | 2022-01-05 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-18 | 2021-10-14 | 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 | 2021-08-18 | 2021-10-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-18 | 2021-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-22 | 2021-10-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-13 | 2021-10-01 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2021-07-13 | 2021-08-05 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-07-13 | 2021-08-05 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-07-13 | 2021-08-05 | 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 | 2021-07-13 | 2021-08-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-13 | 2021-08-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-13 | 2021-08-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-13 | 2021-08-05 | 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 | 2021-07-13 | 2021-08-05 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-13 | 2021-08-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-13 | 2021-08-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-13 | 2021-08-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-07-13 | 2021-08-05 | 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 | 2021-07-13 | 2021-08-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-13 | 2021-08-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-08-06 | 2020-09-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-08-06 | 2020-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-08-06 | 2020-09-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-21 | 2020-03-22 | 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 | 2020-02-21 | 2020-03-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-21 | 2020-03-22 | 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 | 2020-02-21 | 2020-03-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-21 | 2020-03-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-02-21 | 2020-03-22 | 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 | 2020-02-21 | 2020-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-06 | 2020-02-21 | 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 | 2019-09-27 | 2019-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-27 | 2019-10-27 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-04 | 2019-03-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-01-09 | 2019-02-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-01-09 | 2019-02-12 | 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 | 2019-01-09 | 2019-02-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-09 | 2019-02-12 | 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 | 2019-01-09 | 2019-02-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-01-09 | 2019-02-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-09 | 2019-02-12 | 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 | 2019-01-09 | 2019-02-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-09 | 2019-02-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-09 | 2019-02-12 | 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 | 2019-01-09 | 2019-02-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-09 | 2019-02-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-09 | 2019-02-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-09 | 2019-02-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-01-09 | 2019-02-12 | N |
