A list of the most recent deficiencies for Bellbrook Health 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-19 | 2024-01-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-19 | 2024-01-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-19 | 2024-01-08 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-09-26 | 2022-10-20 | 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 | 2022-09-26 | 2022-10-20 | 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 | 2022-09-26 | 2022-10-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-26 | 2022-10-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-26 | 2022-10-20 | N |
| Develop a communication plan. | Fire Safety | 2022-09-19 | 2022-10-20 | 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 | 2022-09-19 | 2022-10-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-09-19 | 2022-10-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-19 | 2022-10-20 | 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 | 2022-09-19 | 2022-10-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-09-19 | 2022-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-19 | 2022-10-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-19 | 2022-10-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-19 | 2022-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-19 | 2022-10-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-09 | 2021-09-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-09 | 2021-09-01 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-04-20 | 2021-05-10 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-04-20 | 2021-05-10 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-11-26 | 2019-12-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-26 | 2019-12-26 | 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 | 2019-11-26 | 2019-12-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-11-26 | 2019-12-26 | 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 | 2019-11-26 | 2019-12-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-26 | 2019-12-26 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-11-26 | 2019-12-26 | N |
| Dispose of garbage and refuse properly. | Health | 2019-11-26 | 2019-12-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-26 | 2019-12-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Develop a communication plan. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-26 | 2019-12-26 | 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 | 2019-11-26 | 2019-12-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-26 | 2019-12-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-01-24 | 2019-05-15 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-01-24 | 2019-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-24 | 2019-04-05 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2019-01-24 | 2019-04-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-01-24 | 2019-04-05 | 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 | 2019-01-24 | 2019-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-24 | 2019-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-24 | 2019-04-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-01-24 | 2019-04-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-01-24 | 2019-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-24 | 2019-04-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-01-24 | 2019-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-24 | 2019-04-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-01-24 | 2019-04-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-24 | 2019-04-05 | N |
