Inspection visit
Inspection
Citations
46 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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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.
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.
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.
F603 - The resident has the right to be free from abuse, neglect, misappropriation
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
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.
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.
F679 - Activities
Provide activities to meet all resident's needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F726 - Nursing Services
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.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
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.
F800 - Food and nutrition services
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
F803 - Menus and nutritional adequacy
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.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0293GeneralS&S Epotential for harm
Have properly located and lighted "Exit" signs.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0325GeneralS&S Fpotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
- 0351GeneralS&S Fpotential for harm
Install an approved automatic sprinkler system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0374GeneralS&S Fpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
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.
- 0900GeneralS&S Epotential for harm
Meet Health Care Facilities Code mechanical requirements.
F912 - Measure at least 80 square feet per resident in multiple resident
Have power receptacles that are properly grounded.
F916 - Have a floor at or above grade level
Have a battery powered remote alarm panel in a location accessible by operating personnel.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the March 8, 2024 survey of Belmont Terrace Nursing and Rehabilitation Center?
This was a inspection survey of Belmont Terrace Nursing and Rehabilitation Center on March 8, 2024. The surveyor cited 46 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Belmont Terrace Nursing and Rehabilitation Center on March 8, 2024?
Yes, 46 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
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.
SourceView on CMS Care Compare
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.