Deficiency Records for Bella Terrace Rehabilitation and Nursing Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Bella Terrace Rehabilitation and Nursing 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? |
|---|---|---|---|---|
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-09-12 | 2023-12-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-30 | 2023-12-28 | 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 | 2023-08-30 | 2023-12-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-30 | 2023-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-30 | 2023-12-28 | 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 | 2023-08-30 | 2023-12-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-30 | 2023-12-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-30 | 2023-12-28 | N |
| Provide appropriate foot care. | Health | 2023-08-30 | 2023-12-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-30 | 2023-12-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-30 | 2023-12-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-30 | 2023-12-28 | 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 | 2023-08-30 | 2023-12-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-30 | 2023-12-28 | 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 | 2023-08-30 | 2023-12-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-30 | 2023-12-28 | 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 | 2023-08-30 | 2023-12-28 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-21 | 2023-12-28 | 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 | 2023-08-21 | 2023-12-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-21 | 2023-12-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-21 | 2023-12-28 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-08-21 | 2023-12-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-21 | 2023-12-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-08-21 | 2023-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-21 | 2023-12-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-21 | 2023-12-28 | N |
| Use approved construction type or materials. | Fire Safety | 2023-08-21 | 2023-09-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-28 | 2023-07-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-28 | 2023-07-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-23 | 2023-07-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-15 | 2023-07-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-28 | 2023-06-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-23 | 2023-03-29 | 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 | 2023-03-23 | 2023-03-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-23 | 2023-03-29 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-30 | 2022-12-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-30 | 2022-12-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-30 | 2022-12-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-12 | 2022-09-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-05 | 2022-09-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-05 | 2022-09-02 | Y |
| 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 | 2022-06-29 | 2022-07-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-15 | 2022-07-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-15 | 2022-07-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-15 | 2022-07-08 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-05-20 | 2022-07-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-20 | 2022-07-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-20 | 2022-07-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-04 | 2022-07-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-04 | 2022-07-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-07 | 2022-07-08 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-07 | 2022-07-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-07 | 2022-07-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-07 | 2022-07-08 | Y |
| 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 | 2022-04-07 | 2022-07-08 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-16 | 2022-07-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-16 | 2022-07-08 | Y |
| Post nurse staffing information every day. | Health | 2022-03-16 | 2022-07-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-16 | 2022-07-08 | Y |
| Dispose of garbage and refuse properly. | Health | 2022-03-16 | 2022-07-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-16 | 2022-07-08 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-16 | 2022-07-08 | Y |
| Report COVID19 data to residents and families. | Health | 2022-03-16 | 2022-07-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-16 | 2022-07-08 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-22 | 2022-07-08 | 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 | 2022-02-22 | 2022-07-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-22 | 2022-07-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-22 | 2022-07-08 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-22 | 2022-07-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-08 | 2021-11-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-08 | 2021-11-22 | 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 | 2021-11-08 | 2021-11-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-10 | 2021-10-15 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-06-07 | 2021-10-15 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-08-26 | 2021-10-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-26 | 2021-10-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-26 | 2021-10-04 | 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 | 2021-08-14 | 2021-10-04 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-08-10 | 2021-10-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-10 | 2021-10-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-10 | 2021-10-04 | 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 | 2021-08-10 | 2021-10-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-10 | 2021-10-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-10 | 2021-10-04 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-10 | 2021-10-04 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-06-07 | 2021-10-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-07 | 2021-10-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-07 | 2021-10-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-07 | 2021-10-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-07 | 2021-10-04 | Y |
| Keep all essential equipment working safely. | Health | 2021-06-07 | 2021-10-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-05 | 2019-12-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-12-05 | 2019-12-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-05 | 2019-12-31 | 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 | 2019-12-05 | 2019-12-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-05 | 2019-12-31 | 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 | 2019-12-05 | 2019-12-31 | 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 | 2019-12-05 | 2019-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-02 | 2019-12-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-02 | 2019-12-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-02 | 2019-12-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-02 | 2019-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-02 | 2019-12-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-11 | 2019-07-31 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-07-11 | 2019-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-11 | 2019-07-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-11 | 2019-07-31 | 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 | 2019-07-11 | 2019-07-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-08 | 2019-07-31 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-07-08 | 2019-07-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-08 | 2019-07-31 | N |
| Use approved construction type or materials. | Fire Safety | 2019-12-02 | Not Fixed | N |
| Use approved construction type or materials. | Fire Safety | 2019-07-08 | Not Fixed | N |
