Deficiency Records for Belltower Health and Rehabilitation Center
Updated as of April 01, 2024
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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-05 | 2023-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-05 | 2023-12-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-05 | 2023-12-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-05 | 2023-12-05 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-09-05 | 2023-12-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-05 | 2023-12-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-05 | 2023-12-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-05 | 2023-12-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-09-05 | 2023-12-05 | 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 | 2023-08-14 | 2023-09-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-14 | 2023-09-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-08-14 | 2023-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-14 | 2023-09-18 | 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 | 2023-08-14 | 2023-09-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-14 | 2023-09-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-14 | 2023-09-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-14 | 2023-09-18 | 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 | 2023-08-14 | 2023-09-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-14 | 2023-09-18 | 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 | 2023-08-14 | 2023-09-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-14 | 2023-09-18 | 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 | 2023-08-14 | 2023-09-18 | 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 | 2023-08-14 | 2023-09-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-14 | 2023-09-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-23 | 2023-04-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-23 | 2023-04-19 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-03-23 | 2023-04-19 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-03-23 | 2023-04-19 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-03 | 2023-01-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-10-03 | 2023-01-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-03 | 2023-01-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-03 | 2023-01-09 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Develop a communication plan. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Have an externally vented heating system. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-03 | 2022-11-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-18 | 2022-09-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-18 | 2022-09-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-18 | 2022-09-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-08-18 | 2022-09-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-18 | 2022-09-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-18 | 2022-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-18 | 2022-09-23 | 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 | 2022-08-18 | 2022-09-23 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-18 | 2022-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-18 | 2022-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-18 | 2022-09-23 | 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 | 2022-08-18 | 2022-09-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-18 | 2022-09-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-18 | 2022-09-23 | 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 | 2022-08-18 | 2022-09-23 | 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 | 2022-08-18 | 2022-09-23 | 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 | 2022-08-18 | 2022-09-23 | 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 | 2022-08-18 | 2022-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-18 | 2022-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-18 | 2022-09-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-18 | 2022-09-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-18 | 2022-09-23 | Y |
| 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 |
