CMS Inspection Results for BELLEFONTAINE GARDENS NURSING & REHAB

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 03/17/2008 Health Survey for BELLEFONTAINE GARDENS NURSING & REHAB

Nutrition and Dietary
Deficiency	Scope	Level of Harm
Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
Develop/implement required procedures for the administration of immunizations.	Widespread	Potential for minimal harm
Resident Rights
Deficiency	Scope	Level of Harm
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Widespread	Minimal harm or potential for actual harm
Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Minimal harm or potential for actual harm
Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Minimal harm or potential for actual harm

 

• 03/17/2008 Fire Safety Survey for BELLEFONTAINE GARDENS NURSING & REHAB

Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm

 

• 01/05/2007 Health Survey for BELLEFONTAINE GARDENS NURSING & REHAB

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Check and update (if needed) each resident's assessment every 3 months.	Pattern	Minimal harm or potential for actual harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States.	Pattern	Minimal harm or potential for actual harm

 

• 01/05/2007 Fire Safety Survey for BELLEFONTAINE GARDENS NURSING & REHAB

Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm

 

• 03/15/2006 Health Survey for BELLEFONTAINE GARDENS NURSING & REHAB

Administration
Deficiency	Scope	Level of Harm
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm

 

• 03/15/2006 Fire Safety Survey for BELLEFONTAINE GARDENS NURSING & REHAB

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm