Deficiency Records for Beloved Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Beloved 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? |
|---|---|---|---|---|
| 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-05 | 2023-01-31 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | 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 |
| Protect each resident from the wrongful use of the resident's belongings or money. | 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 |
| 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 |
| Ensure each resident receives an accurate assessment. | 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 |
| 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 |
| 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 |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 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 |
| 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 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 |
| 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 |
| 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 | Y |
| 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 | Y |
| 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 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-07 | 2023-01-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-07 | 2023-01-21 | Y |
| 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 | Y |
| 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 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-07 | 2023-01-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-07 | 2023-01-21 | Y |
| 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 | Y |
| 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 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-12-07 | 2023-01-21 | Y |
| 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 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-12-07 | 2023-01-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-12-07 | 2023-01-21 | N |
| Establish policies and procedures including evacuation. | 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 roles under a Waiver declared by secretary. | 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 emergency prep training and testing. | Fire Safety | 2022-12-07 | 2023-01-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-07 | 2023-01-21 | N |
| Implement emergency and standby power systems. | 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 |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 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 |
| Provide properly protected cooking facilities. | Fire Safety | 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 |
| 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 |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 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 |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-07 | 2023-01-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-07 | 2022-08-01 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-02 | 2022-05-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-30 | 2021-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-30 | 2021-12-30 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-24 | 2021-12-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-24 | 2021-12-30 | 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 | 2021-09-24 | 2021-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-24 | 2021-12-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-24 | 2021-12-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-24 | 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 | 2021-09-24 | 2021-11-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-24 | 2021-11-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-24 | 2021-11-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-24 | 2021-11-07 | Y |
| 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 | 2021-09-24 | 2021-11-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-24 | 2021-11-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-24 | 2021-11-07 | 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 | 2021-09-24 | 2021-11-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-24 | 2021-11-07 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-24 | 2021-11-07 | 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 | 2021-09-24 | 2021-11-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-24 | 2021-11-07 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | 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 care and assistance to perform activities of daily living for any resident who is unable. | 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 appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| 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 |
| 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 |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | 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 |
| 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 |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-02-16 | 2018-03-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-16 | 2018-03-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-16 | 2018-03-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-02-16 | 2018-03-23 | N |
| Post nurse staffing information every day. | Health | 2018-02-16 | 2018-03-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-02-16 | 2018-03-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-16 | 2018-03-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-02-16 | 2018-03-23 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-02-16 | 2018-03-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-02-16 | 2018-03-23 | N |
| Meet other general requirements. | Fire Safety | 2018-02-16 | 2018-03-23 | N |
