Bella Terra St George (Black Rock Health and Rehab

This section preserves official CMS inspection text matched to this facility from the current provider page source.

B6-INSP Inspections and official narratives P1 DIFF
CMS Health Deficiencies rows stay the citation spine. CMS Form 2567 inspection content is shown for this facility's cited F-tags and survey dates.
CMS scope and severity
Isolated
Pattern
Widespread
Immediate jeopardy
J
K
L
Actual harm
G
H
I
No harm, potential
D 2
E
F
Minimal harm
A
B
C
Shaded cells were cited in the latest survey cycle. Down and right is more serious.
Deficiency trend
Health deficiencies by cycle: 2, then 56, then 6 . Latest survey date: 2026-01-08.
Repeat citations
Tag Plain English Previous Latest Sev No repeat deficiency tags found between the latest two CMS cycles in this available CMS data snapshot. CMS data shows 0 repeat deficiency tags between the latest two cycles.
Recent citations
Date Tag Category Sev Found how Corrected 2026-01-08 F0605 Resident protection deficiencies D standard 2026-01-23 2026-01-08 F0757 Pharmacy Service Deficiencies D standard 2026-01-23
Official CMS inspection narrative
F0605 · 2026-01-08 · severity D
Official inspection narrative not available for this citation.
F0757 · 2026-01-08 · severity D
Official inspection narrative not available for this citation.
CMS Form 2567 inspection report text
The inspection text below is attributed to CMS Form 2567 records when a matching official source is available.
Inspection Report:
2024-11-13
This report is the official CMS Statement of Deficiencies (Form 2567) filed after the most recent health inspection.
Each
56
is a federal standard the facility failed to meet.
Read the full inspection report
Survey: 2024-11-13 | Tag F0550 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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Survey: 2024-11-13 | Tag F0553 | Resident Rights Deficiencies | Severity: D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
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Survey: 2024-11-13 | Tag F0558 | Resident Rights Deficiencies | Severity: D
Reasonably accommodate the needs and preferences of each resident.
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Survey: 2024-11-13 | Tag F0576 | Resident Rights Deficiencies | Severity: D
Ensure residents have reasonable access to and privacy in their use of communication methods.
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Survey: 2024-11-13 | Tag F0578 | Resident Rights Deficiencies | Severity: D
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.
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Survey: 2024-11-13 | Tag F0584 | Resident Rights Deficiencies | Severity: E
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.
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Survey: 2024-11-13 | Tag F0585 | Resident Rights Deficiencies | Severity: E
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.
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Survey: 2024-11-13 | Tag F0600 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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Survey: 2024-11-13 | Tag F0602 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Protect each resident from the wrongful use of the resident's belongings or money.
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Survey: 2024-11-13 | Tag F0603 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: G
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
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Survey: 2024-11-13 | Tag F0607 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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Survey: 2024-11-13 | Tag F0609 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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Survey: 2024-11-13 | Tag F0610 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Severity: D
Respond appropriately to all alleged violations.
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Survey: 2024-11-13 | Tag F0622 | Resident Rights Deficiencies | Severity: D
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.
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Survey: 2024-11-13 | Tag F0624 | Resident Rights Deficiencies | Severity: D
Prepare residents for a safe transfer or discharge from the nursing home.
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Survey: 2024-11-13 | Tag F0625 | Resident Rights Deficiencies | Severity: E
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.
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Survey: 2024-11-13 | Tag F0635 | Resident Assessment and Care Planning Deficiencies | Severity: D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
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Survey: 2024-11-13 | Tag F0640 | Resident Assessment and Care Planning Deficiencies | Severity: D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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Survey: 2024-11-13 | Tag F0641 | Resident Assessment and Care Planning Deficiencies | Severity: E
Ensure each resident receives an accurate assessment.
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Survey: 2024-11-13 | Tag F0655 | Resident Assessment and Care Planning Deficiencies | Severity: E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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Survey: 2024-11-13 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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Survey: 2024-11-13 | Tag F0676 | Quality of Life and Care Deficiencies | Severity: E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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Survey: 2024-11-13 | Tag F0679 | Quality of Life and Care Deficiencies | Severity: D
Provide activities to meet all resident's needs.
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Survey: 2024-11-13 | Tag F0686 | Quality of Life and Care Deficiencies | Severity: G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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Survey: 2024-11-13 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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Survey: 2024-11-13 | Tag F0690 | Quality of Life and Care Deficiencies | Severity: G
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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Survey: 2024-11-13 | Tag F0691 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
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Survey: 2024-11-13 | Tag F0692 | Quality of Life and Care Deficiencies | Severity: E
Provide enough food/fluids to maintain a resident's health.
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Survey: 2024-11-13 | Tag F0725 | Nursing and Physician Services Deficiencies | Severity: H
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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Survey: 2024-11-13 | Tag F0726 | Nursing and Physician Services Deficiencies | Severity: H
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.
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Survey: 2024-11-13 | Tag F0732 | Nursing and Physician Services Deficiencies | Severity: D
Post nurse staffing information every day.
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Survey: 2024-11-13 | Tag F0740 | Quality of Life and Care Deficiencies | Severity: G
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
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Survey: 2024-11-13 | Tag F0744 | Quality of Life and Care Deficiencies | Severity: D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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Survey: 2024-11-13 | Tag F0755 | Pharmacy Service Deficiencies | Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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Survey: 2024-11-13 | Tag F0758 | Pharmacy Service Deficiencies | Severity: E
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.
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Survey: 2024-11-13 | Tag F0770 | Administration Deficiencies | Severity: D
Provide timely, quality laboratory services/tests to meet the needs of residents.
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Survey: 2024-11-13 | Tag F0775 | Administration Deficiencies | Severity: E
Keep complete, dated laboratory records in the resident's record.
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Survey: 2024-11-13 | Tag F0800 | Nutrition and Dietary Deficiencies | Severity: F
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
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Survey: 2024-11-13 | Tag F0802 | Nutrition and Dietary Deficiencies | Severity: G
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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Survey: 2024-11-13 | Tag F0803 | Nutrition and Dietary Deficiencies | Severity: E
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.
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Survey: 2024-11-13 | Tag F0804 | Nutrition and Dietary Deficiencies | Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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Survey: 2024-11-13 | Tag F0806 | Nutrition and Dietary Deficiencies | Severity: E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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Survey: 2024-11-13 | Tag F0807 | Nutrition and Dietary Deficiencies | Severity: E
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
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Survey: 2024-11-13 | Tag F0808 | Nutrition and Dietary Deficiencies | Severity: D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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Survey: 2024-11-13 | Tag F0809 | Nutrition and Dietary Deficiencies | Severity: E
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.
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Survey: 2024-11-13 | Tag F0810 | Nutrition and Dietary Deficiencies | Severity: D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
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Survey: 2024-11-13 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2024-11-13 | Tag F0835 | Administration Deficiencies | Severity: H
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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Survey: 2024-11-13 | Tag F0842 | Resident Assessment and Care Planning Deficiencies | Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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Survey: 2024-11-13 | Tag F0849 | Administration Deficiencies | Severity: D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
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Survey: 2024-11-13 | Tag F0867 | Administration Deficiencies | Severity: H
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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Survey: 2024-11-13 | Tag F0880 | Infection Control Deficiencies | Severity: F
Provide and implement an infection prevention and control program.
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Survey: 2024-11-13 | Tag F0881 | Infection Control Deficiencies | Severity: D
Implement a program that monitors antibiotic use.
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Survey: 2024-11-13 | Tag F0883 | Infection Control Deficiencies | Severity: D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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Survey: 2024-11-13 | Tag F0887 | Infection Control Deficiencies | Severity: E
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.
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Survey: 2024-11-13 | Tag F0919 | Environmental Deficiencies | Severity: E
Make sure that a working call system is available in each resident's bathroom and bathing area.
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Survey: 2023-06-28 | Tag F0655 | Resident Assessment and Care Planning Deficiencies | Severity: D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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Survey: 2023-06-28 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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Survey: 2023-06-28 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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Survey: 2023-06-28 | Tag F0690 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
---
Survey: 2023-06-28 | Tag F0744 | Quality of Life and Care Deficiencies | Severity: D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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Survey: 2023-06-28 | Tag F0881 | Infection Control Deficiencies | Severity: D
Implement a program that monitors antibiotic use.
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Survey: 2021-09-16 | Tag F0550 | Resident Rights Deficiencies | Severity: E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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Survey: 2021-09-16 | Tag F0558 | Resident Rights Deficiencies | Severity: D
Reasonably accommodate the needs and preferences of each resident.
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Survey: 2021-09-16 | Tag F0567 | Resident Rights Deficiencies | Severity: E
Honor the resident's right to manage his or her financial affairs.
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Survey: 2021-09-16 | Tag F0576 | Resident Rights Deficiencies | Severity: E
Ensure residents have reasonable access to and privacy in their use of communication methods.
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Survey: 2021-09-16 | Tag F0580 | Resident Rights Deficiencies | Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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Survey: 2021-09-16 | Tag F0582 | Resident Rights Deficiencies | Severity: D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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Survey: 2021-09-16 | Tag F0584 | Resident Rights Deficiencies | Severity: E
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.
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Survey: 2021-09-16 | Tag F0585 | Resident Rights Deficiencies | Severity: D
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.
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Survey: 2021-09-16 | Tag F0636 | Resident Assessment and Care Planning Deficiencies | Severity: D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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Survey: 2021-09-16 | Tag F0638 | Resident Assessment and Care Planning Deficiencies | Severity: E
Assure that each resident’s assessment is updated at least once every 3 months.
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Survey: 2021-09-16 | Tag F0640 | Resident Assessment and Care Planning Deficiencies | Severity: E
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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Survey: 2021-09-16 | Tag F0641 | Resident Assessment and Care Planning Deficiencies | Severity: D
Ensure each resident receives an accurate assessment.
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Survey: 2021-09-16 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
---
Survey: 2021-09-16 | Tag F0676 | Quality of Life and Care Deficiencies | Severity: D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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Survey: 2021-09-16 | Tag F0679 | Quality of Life and Care Deficiencies | Severity: D
Provide activities to meet all resident's needs.
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Survey: 2021-09-16 | Tag F0688 | Quality of Life and Care Deficiencies | Severity: D
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.
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Survey: 2021-09-16 | Tag F0690 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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Survey: 2021-09-16 | Tag F0695 | Quality of Life and Care Deficiencies | Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
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Survey: 2021-09-16 | Tag F0725 | Nursing and Physician Services Deficiencies | Severity: E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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Survey: 2021-09-16 | Tag F0742 | Quality of Life and Care Deficiencies | Severity: G
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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Survey: 2021-09-16 | Tag F0758 | Pharmacy Service Deficiencies | Severity: D
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.
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Survey: 2021-09-16 | Tag F0773 | Administration Deficiencies | Severity: D
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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Survey: 2021-09-16 | Tag F0801 | Nutrition and Dietary Deficiencies | Severity: F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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Survey: 2021-09-16 | Tag F0802 | Nutrition and Dietary Deficiencies | Severity: E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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Survey: 2021-09-16 | Tag F0803 | Nutrition and Dietary Deficiencies | Severity: E
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.
---
Survey: 2021-09-16 | Tag F0804 | Nutrition and Dietary Deficiencies | Severity: E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
---
Survey: 2021-09-16 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
---
Survey: 2021-09-16 | Tag F0840 | Administration Deficiencies | Severity: E
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
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Survey: 2021-09-16 | Tag F0842 | Resident Assessment and Care Planning Deficiencies | Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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Survey: 2021-09-16 | Tag F0849 | Administration Deficiencies | Severity: D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
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Survey: 2021-09-16 | Tag F0865 | Administration Deficiencies | Severity: E
Have a plan that describes the process for conducting QAPI and QAA activities.
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Survey: 2021-09-16 | Tag F0867 | Administration Deficiencies | Severity: D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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Survey: 2021-09-16 | Tag F0868 | Administration Deficiencies | Severity: D
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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Survey: 2021-09-16 | Tag F0880 | Infection Control Deficiencies | Severity: E
Provide and implement an infection prevention and control program.
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Survey: 2021-09-16 | Tag F0886 | Infection Control Deficiencies | Severity: E
Perform COVID19 testing on residents and staff.
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Survey: 2021-09-16 | Tag F0887 | Infection Control Deficiencies | Severity: E
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.
Source: U.S. Centers for Medicare & Medicaid Services. Data reflects the most recent available inspection.
Source rule. Official inspection text is quoted verbatim only when an official CMS Form 2567 source matches the CMS citation row. Citations without a matching official narrative remain labeled as not available.