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Inspection visit

Inspection

Belmont Terrace Nursing and Rehabilitation CenterCMS #18509022 citations on this visit
22 citations recorded

Citations

22 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0363GeneralS&S Dpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0741GeneralS&S Dpotential for harm

    F741 - The facility must have sufficient staff who provide direct services to

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  • 0781GeneralS&S Dpotential for harm

    Have restrictions on the use of portable space heaters.

  • 0923GeneralS&S Dpotential for harm

    F923 - Have adequate outside ventilation by means of windows, or mechanical

    Have proper medical gas storage and administration areas.

  • 0580SeriousS&S Jimmediate jeopardy

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0584GeneralS&S Fpotential for harm

    F584 - Safe Environment

    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.

  • 0600GeneralS&S Epotential for harm

    F600 - Freedom from Abuse, Neglect, and Exploitation

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0602GeneralS&S Dpotential for harm

    F602 - The resident has the right to be free from abuse, neglect, misappropriation of re

    Protect each resident from the wrongful use of the resident's belongings or money.

  • 0656SeriousS&S Jimmediate jeopardy

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657SeriousS&S Jimmediate jeopardy

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0661SeriousS&S Jimmediate jeopardy

    F661 - Quality of life

    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0686SeriousS&S Jimmediate jeopardy

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0695SeriousS&S Jimmediate jeopardy

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0697GeneralS&S Dpotential for harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0756GeneralS&S Epotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0757GeneralS&S Epotential for harm

    F757 - Unnecessary Drugs—General

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    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.

  • 0761GeneralS&S Fpotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0835GeneralS&S Fpotential for harm

    F835 - Administration

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the May 14, 2021 survey of Belmont Terrace Nursing and Rehabilitation Center?

This was a inspection survey of Belmont Terrace Nursing and Rehabilitation Center on May 14, 2021. The surveyor cited 22 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Belmont Terrace Nursing and Rehabilitation Center on May 14, 2021?

Yes, 22 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Install corridor and hallway doors that block smoke."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.