Deficiency Records for Belmont Care and Rehabilitation
Updated as of April 01, 2023
This is not the most recent data for Belmont Care and Rehabilitation. For the most recent information, click here.
A list of the most recent deficiencies for Belmont Care and Rehabilitation. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-10 | 2023-03-22 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-02-10 | 2023-03-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-10 | 2023-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-12 | 2022-11-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-07 | 2022-04-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-07 | 2022-04-28 | 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 | 2022-03-07 | 2022-04-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-07 | 2022-04-28 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-03 | 2022-04-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-03 | 2022-04-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-03 | 2022-04-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-07 | 2022-04-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-07 | 2022-04-15 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-03 | 2022-04-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-03 | 2022-04-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-05 | 2021-03-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-05 | 2021-03-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-02-05 | 2021-03-27 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-02-05 | 2021-03-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-08-06 | 2020-09-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-08-06 | 2020-09-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-08-06 | 2020-09-09 | 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 | 2020-08-06 | 2020-09-09 | Y |
| 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 | 2020-08-06 | 2020-09-09 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-08-06 | 2020-09-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-08-06 | 2020-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-08-06 | 2020-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-04-23 | 2020-04-28 | 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 | 2019-02-08 | 2019-05-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-02-08 | 2019-03-27 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-02-08 | 2019-03-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-08 | 2019-03-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-08 | 2019-03-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-08 | 2019-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-08 | 2019-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-08 | 2019-03-27 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-02-08 | 2019-03-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-08 | 2019-03-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-02-08 | 2019-03-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-08 | 2019-03-27 | 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 | 2019-02-08 | 2019-03-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-08 | 2019-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-08 | 2019-03-27 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-01-30 | 2019-03-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-01-30 | 2019-03-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-01-30 | 2019-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-30 | 2019-03-12 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-01-30 | 2019-03-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2017-12-18 | 2018-03-08 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2017-12-13 | 2018-02-07 | N |
| Develop a communication plan. | Fire Safety | 2017-12-13 | 2018-02-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2017-12-13 | 2018-02-07 | 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 | 2017-12-13 | 2018-02-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-12-13 | 2018-02-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-12-13 | 2018-02-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2017-12-18 | 2018-01-31 | 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 | 2017-12-18 | 2018-01-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2017-12-18 | 2018-01-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-18 | 2018-01-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2017-12-18 | 2018-01-31 | 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 | 2017-12-18 | 2018-01-31 | N |
