Deficiency Records for Bellefontaine Gardens Nursing and Rehab
Updated as of March 01, 2024
A list of the most recent deficiencies for Bellefontaine Gardens Nursing and Rehab. 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? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-04-08 | 2022-04-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-08 | 2022-04-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-01 | 2022-04-08 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-03-01 | 2022-04-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-01 | 2022-04-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-01 | 2022-04-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-01 | 2022-03-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-01 | 2021-09-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-22 | 2021-09-28 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-09 | 2021-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-22 | 2021-07-09 | 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 | 2021-04-28 | 2021-06-22 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-04-28 | 2021-06-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-28 | 2021-06-21 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-09 | 2021-06-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-28 | 2021-06-10 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-04-28 | 2021-06-10 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-04-28 | 2021-06-10 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2021-04-28 | 2021-06-10 | 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 | 2021-04-28 | 2021-06-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-28 | 2021-06-10 | 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 | 2021-04-28 | 2021-06-10 | 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 | 2021-04-28 | 2021-06-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-28 | 2021-06-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-28 | 2021-06-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-28 | 2021-06-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-04-28 | 2021-06-10 | 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 | 2021-04-28 | 2021-06-10 | 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 | 2021-04-28 | 2021-06-10 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-04-28 | 2021-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-28 | 2021-06-10 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-28 | 2021-06-10 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-04-28 | 2021-06-10 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-04-28 | 2021-06-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-28 | 2021-06-10 | Y |
| 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 | 2021-04-28 | 2021-06-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-28 | 2021-06-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-28 | 2021-06-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-28 | 2021-06-10 | 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 | 2021-04-28 | 2021-06-10 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-04-28 | 2021-06-10 | 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 | 2021-04-28 | 2021-06-10 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-09 | 2021-05-21 | 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 | 2021-04-09 | 2021-05-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-09 | 2021-05-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-28 | 2021-04-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-28 | 2021-04-28 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-01 | 2019-07-08 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-05-01 | 2019-06-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-05-01 | 2019-06-12 | 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 | 2019-05-01 | 2019-06-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-01 | 2019-06-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-05-01 | 2019-06-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-01 | 2019-06-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-01 | 2019-06-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-01 | 2019-06-12 | 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 | 2019-05-01 | 2019-06-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-01 | 2019-06-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-01 | 2019-06-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-01 | 2019-06-12 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-01 | 2019-06-12 | 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 | 2019-05-01 | 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 | 2019-05-01 | 2019-06-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-01 | 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 | 2019-05-01 | 2019-06-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-01 | 2019-06-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-01 | 2019-06-12 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-05-01 | 2019-06-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-05-01 | 2019-06-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-01 | 2019-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-01 | 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 | 2019-05-01 | 2019-06-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-01 | 2019-06-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-01 | 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 | 2018-03-09 | 2018-05-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-09 | 2018-05-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-09 | 2018-05-04 | 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 | 2018-03-09 | 2018-05-04 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-03-09 | 2018-04-22 | 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 | 2018-03-09 | 2018-04-22 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-09 | 2018-04-22 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-03-09 | 2018-04-22 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-03-09 | 2018-04-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-09 | 2018-04-22 | 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 | 2018-03-09 | 2018-04-22 | 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 | 2018-03-09 | 2018-04-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-03-09 | 2018-04-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-03-09 | 2018-04-22 | 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 | 2018-03-09 | 2018-04-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-09 | 2018-04-22 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-03-09 | 2018-04-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-03-09 | 2018-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-09 | 2018-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-09 | 2018-04-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-09 | 2018-04-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-09 | 2018-04-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-09 | 2018-04-22 | N |
