CONTACT INFORMATION REVIEWS & MORE DATA

Deficiency Records for Beloved Health and Rehabilitation Center

View the most recent health deficiencies and inspection results for Beloved Health and Rehabilitation Center. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Beloved Health and Rehabilitation Center. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-04-04 2025-03-28 Y
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2025-02-05 2025-03-17 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-11-27 2025-03-17 N
Provide a written emergency evacuation plan. Fire Safety 2024-11-27 2025-03-17 N
Provide and implement an infection prevention and control program. Health 2024-11-27 2025-03-17 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-11-27 2025-03-17 Y
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2024-11-27 2025-03-17 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-02-05 2025-03-17 Y
Assure the security of all personal funds of residents deposited with the facility. Health 2024-11-27 2025-01-13 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 2024-11-27 2025-01-13 N
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Health 2024-11-27 2025-01-13 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 2024-11-27 2025-01-13 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 2024-11-27 2025-01-13 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 2024-11-27 2025-01-13 N
Provide appropriate foot care. Health 2024-11-27 2025-01-13 N
Assist a resident in gaining access to vision and hearing services. Health 2024-11-27 2025-01-13 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-11-27 2025-01-13 N
Provide or obtain dental services for each resident. Health 2024-11-27 2025-01-13 N
Ensure each resident receives an accurate assessment. Health 2024-11-27 2025-01-13 N
Assess the resident when there is a significant change in condition Health 2024-11-27 2025-01-13 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2024-11-27 2025-01-13 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 2024-11-27 2025-01-13 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-11-27 2025-01-13 N
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. Health 2024-11-27 2025-01-13 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2024-11-27 2025-01-13 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 2024-11-27 2025-01-13 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2024-11-27 2025-01-13 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2024-11-27 2025-01-13 N
Give residents a notice of rights, rules, services and charges. Health 2024-11-27 2025-01-13 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2024-11-27 2025-01-13 N
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2024-11-27 2025-01-13 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2024-11-27 2025-01-13 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-11-27 2025-01-13 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2024-11-27 2025-01-13 Y
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Health 2024-11-27 2025-01-13 Y
Honor the resident's right to manage his or her financial affairs. Health 2024-11-27 2025-01-13 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-11-27 2025-01-13 Y
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Health 2024-11-27 2025-01-13 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2024-11-27 2025-01-13 N
Provide training in compliance and ethics. Health 2024-11-27 2025-01-13 N
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Health 2024-11-27 2025-01-13 N
Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. Health 2024-11-27 2025-01-13 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 2024-11-27 2025-01-13 N
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Health 2024-11-27 2025-01-13 N
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Health 2024-11-27 2025-01-13 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2024-11-27 2025-01-13 N
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2024-11-27 2025-01-13 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-11-27 2025-01-13 N
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Health 2024-11-27 2025-01-13 N
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Health 2024-11-27 2025-01-13 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2024-11-27 2025-01-13 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-11-27 2025-01-13 N
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2024-11-27 2025-01-13 N
Meet requirements for the use of electrical equipment. Fire Safety 2024-11-27 2025-01-13 N
Establish policies and procedures including evacuation. Fire Safety 2024-11-27 2025-01-13 N
Create arrangements with other facilities to receive patients. Fire Safety 2024-11-27 2025-01-13 N
Establish roles under a Waiver declared by secretary. Fire Safety 2024-11-27 2025-01-13 N
Conduct testing and exercise requirements. Fire Safety 2024-11-27 2025-01-13 N
Implement emergency and standby power systems. Fire Safety 2024-11-27 2025-01-13 N
Meet other general requirements. Fire Safety 2024-11-27 2025-01-13 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2024-11-27 2025-01-13 N
Have proper medical gas storage and administration areas. Fire Safety 2024-11-27 2025-01-13 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2024-11-27 2025-01-13 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-11-27 2025-01-13 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2024-11-27 2025-01-13 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-11-27 2025-01-13 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-11-27 2025-01-13 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-11-27 2025-01-13 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-11-27 2025-01-13 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-11-27 2025-01-13 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-11-27 2025-01-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-11-27 2025-01-13 N
Have an enclosure around a vertical opening shaft. Fire Safety 2024-11-27 2025-01-13 N
Provide properly protected cooking facilities. Fire Safety 2024-11-27 2025-01-13 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 2024-11-27 2025-01-13 N
Reasonably accommodate the needs and preferences of each resident. Health 2024-11-27 2025-01-13 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-03-28 2024-09-25 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2024-03-28 2024-09-25 Y
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2024-03-28 2024-09-25 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2024-03-28 2024-09-25 Y
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 2024-03-28 2024-09-25 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-03-28 2024-09-25 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-03-28 2024-09-25 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-03-28 2024-09-25 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 2024-03-28 2024-09-25 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2024-03-28 2024-09-25 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-06-18 2024-09-25 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2024-05-29 2024-09-25 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 2024-05-29 2024-09-25 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-06-18 2024-09-25 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2024-08-02 2024-09-25 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-08-02 2024-09-25 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-08-02 2024-09-25 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-08-02 2024-09-25 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 2024-08-02 2024-09-25 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-08-02 2024-09-25 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-09-10 2024-08-22 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-06-18 2024-07-22 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-06-18 2024-07-22 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-05-29 2024-06-26 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-03-28 2024-06-26 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-04-18 2024-05-24 Y
Provide and implement an infection prevention and control program. Health 2024-03-28 2024-05-14 Y
Ensure that residents are free from significant medication errors. Health 2024-03-28 2024-05-14 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2024-02-07 2024-03-19 Y
Provide routine and 24-hour emergency dental care for each resident. Health 2024-02-07 2024-03-19 Y
Respond appropriately to all alleged violations. Health 2024-02-07 2024-03-19 Y
Provide or get specialized rehabilitative services as required for a resident. Health 2023-12-06 2024-01-22 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-12-06 2024-01-22 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-12-06 2024-01-22 Y
Honor the resident's right to manage his or her financial affairs. Health 2023-11-03 2023-12-04 Y
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2023-08-09 2023-09-14 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2022-12-07 2023-01-21 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-12-07 2023-01-21 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-12-07 2023-01-21 N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2022-12-07 2023-01-21 N
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Health 2022-12-07 2023-01-21 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 2022-12-07 2023-01-21 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 2022-12-07 2023-01-21 N
Post nurse staffing information every day. Health 2022-12-07 2023-01-21 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 2022-12-07 2023-01-21 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 2022-12-07 2023-01-21 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-12-07 2023-01-21 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-12-07 2023-01-21 N
Provide and implement an infection prevention and control program. Health 2022-12-07 2023-01-21 N
Implement a program that monitors antibiotic use. Health 2022-12-07 2023-01-21 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-12-07 2023-01-21 N
Perform COVID19 testing on residents and staff. Health 2022-12-07 2023-01-21 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-12-07 2023-01-21 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 2022-12-07 2023-01-21 N
Have proper medical gas storage and administration areas. Fire Safety 2022-12-07 2023-01-21 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-12-07 2023-01-21 N
Conduct testing and exercise requirements. Fire Safety 2022-12-07 2023-01-21 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2022-12-07 2023-01-21 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-12-07 2023-01-21 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-12-07 2023-01-21 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 2022-12-07 2023-01-21 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 2022-12-07 2023-01-21 N
Have an enclosure around a vertical opening shaft. Fire Safety 2022-12-07 2023-01-21 N
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Fire Safety 2022-12-07 2023-01-21 N
Implement emergency and standby power systems. Fire Safety 2022-12-07 2023-01-21 N
Provide properly protected cooking facilities. Fire Safety 2022-12-07 2023-01-21 N
Establish emergency prep training and testing. Fire Safety 2022-12-07 2023-01-21 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2022-12-07 2023-01-21 N
Establish roles under a Waiver declared by secretary. Fire Safety 2022-12-07 2023-01-21 N
Establish policies and procedures for volunteers. Fire Safety 2022-12-07 2023-01-21 N
Establish policies and procedures including evacuation. Fire Safety 2022-12-07 2023-01-21 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2022-12-07 2023-01-21 N
Address patient/client population and determine types of services needed. Fire Safety 2022-12-07 2023-01-21 N
Respond appropriately to all alleged violations. Health 2022-12-07 2023-01-21 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-12-07 2023-01-21 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-12-07 2023-01-21 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-12-07 2023-01-21 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-12-07 2023-01-21 N
Ensure each resident receives an accurate assessment. Health 2022-12-07 2023-01-21 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-12-07 2023-01-21 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 2022-12-07 2023-01-21 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-12-07 2023-01-21 N
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Health 2022-12-07 2023-01-21 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-12-07 2023-01-21 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-12-07 2023-01-21 N
Protect each resident from the wrongful use of the resident's belongings or money. Health 2022-12-07 2023-01-21 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 2022-12-07 2023-01-21 N
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Health 2022-12-07 2023-01-21 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 2019-05-02 2019-06-12 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-05-02 2019-06-12 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 2019-05-02 2019-06-12 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 2019-05-02 2019-06-12 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-05-02 2019-06-12 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2019-05-02 2019-06-12 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-05-02 2019-06-12 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-05-02 2019-06-12 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2019-05-02 2019-06-12 N
Provide and implement an infection prevention and control program. Health 2019-05-02 2019-06-12 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2019-05-02 2019-06-12 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2019-05-02 2019-06-12 N
Establish policies and procedures including evacuation. Fire Safety 2019-05-02 2019-06-12 N
Use approved construction type or materials. Fire Safety 2019-05-02 2019-06-12 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-05-02 2019-06-12 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 2019-05-02 2019-06-12 N
Provide properly protected cooking facilities. Fire Safety 2019-05-02 2019-06-12 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-05-02 2019-06-12 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2019-05-02 2019-06-12 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2019-05-02 2019-06-12 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-11-27 Not Fixed N

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