Deficiency Records for Bellefontaine Gardens Nursing and Rehab
Updated as of November 01, 2020
This is not the most recent data for Bellefontaine Gardens Nursing and Rehab. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-19 | 2020-03-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-05 | 2020-03-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-05 | 2020-03-04 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-05-01 | 2019-07-08 | N |
| Post nurse staffing information every day. | Health | 2019-06-11 | 2019-06-25 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-06-11 | 2019-06-25 | Y |
| 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 |
| 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 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 |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-01 | 2019-06-12 | Y |
| 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 | 2019-01-11 | 2019-01-25 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-01-11 | 2019-01-25 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-01-11 | 2019-01-25 | 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 | 2018-03-09 | 2018-05-22 | 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 |
| 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 |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | Health | 2018-01-08 | 2018-01-25 | Y |
| Use approved construction type or materials. | Fire Safety | 2017-03-29 | 2017-05-22 | 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 | 2017-03-29 | 2017-05-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-03-29 | 2017-05-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-03-29 | 2017-05-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-03-29 | 2017-05-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-03-29 | 2017-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-03-29 | 2017-05-22 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2017-03-29 | 2017-05-22 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-03-29 | 2017-05-22 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-03-29 | 2017-05-22 | N |
| 1) Protect current or future residents from giving up their Medicaid or Medicare benefits; or 2) follow federal rules for admissions. | Health | 2017-03-29 | 2017-05-22 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-29 | 2017-05-22 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-29 | 2017-05-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-03-29 | 2017-05-22 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-03-29 | 2017-05-22 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-03-29 | 2017-05-22 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-29 | 2017-05-22 | N |
