A list of the most recent deficiencies for Bellbrook. 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 and implement an infection prevention and control program. | Health | 2024-01-10 | 2024-02-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-09 | 2024-02-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-09 | 2024-02-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-09 | 2024-02-07 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-01-09 | 2024-02-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Have a combustible roofing system that meets safety standards. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-14 | 2023-01-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-14 | 2023-01-19 | 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 | 2022-12-14 | 2023-01-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-14 | 2023-01-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-14 | 2023-01-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-14 | 2023-01-17 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-09-14 | 2021-10-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-14 | 2021-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-14 | 2021-10-14 | N |
