Deficiency Records for Belmont Bay Rehabilitation and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Belmont Bay Rehabilitation and Healthcare 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-03 | 2022-09-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-03 | 2022-09-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-21 | 2022-09-01 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2022-07-21 | 2022-09-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-07-21 | 2022-09-01 | N |
| 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 | 2022-07-21 | 2022-09-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-21 | 2022-09-01 | 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 | 2022-07-21 | 2022-09-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-21 | 2022-09-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-21 | 2022-09-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-21 | 2022-09-01 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-07-21 | 2022-09-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-07-21 | 2022-09-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-21 | 2022-09-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-21 | 2022-09-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-21 | 2022-09-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-21 | 2022-09-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-07-21 | 2022-09-01 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-07-21 | 2022-09-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-21 | 2022-09-01 | N |
| 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 | 2022-07-21 | 2022-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-21 | 2022-09-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-07-21 | 2022-09-01 | 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 | 2022-07-21 | 2022-09-01 | Y |
| 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 | 2022-07-21 | 2022-09-01 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2022-07-21 | 2022-09-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-21 | 2022-09-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-04 | 2021-08-24 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-08-04 | 2021-08-24 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-02-12 | 2021-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-05 | 2020-04-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-03-05 | 2020-04-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-03-05 | 2020-04-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-05 | 2020-04-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-03-05 | 2020-04-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-03-05 | 2020-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-05 | 2020-04-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-03-05 | 2020-04-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-05 | 2020-04-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-05 | 2020-04-14 | 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 | 2020-03-05 | 2020-04-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-03-05 | 2020-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-05 | 2020-04-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-03-05 | 2020-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-05 | 2020-04-14 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-03-05 | 2020-04-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-18 | 2019-03-05 | 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 | 2018-12-18 | 2019-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-18 | 2019-03-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-18 | 2019-03-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-18 | 2019-03-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-18 | 2019-03-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-18 | 2019-03-05 | N |
| Have an externally vented heating system. | Fire Safety | 2018-12-18 | 2019-03-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-18 | 2019-03-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-18 | 2019-03-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-12-06 | 2019-01-08 | 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 | 2018-12-06 | 2019-01-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-06 | 2019-01-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-06 | 2019-01-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-06 | 2019-01-08 | 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 | 2018-12-06 | 2019-01-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-06 | 2019-01-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-12-06 | 2019-01-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-12-06 | 2019-01-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-06 | 2019-01-08 | N |
