Deficiency Records for Avamere Bellingham Health Care and Rehab Services
Updated as of October 01, 2018
This is not the most recent data for Avamere Bellingham Health Care and Rehab Services. For the most recent information, click here.
A list of the most recent deficiencies for Avamere Bellingham Health Care and Rehab Services. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-18 | 2018-07-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-05-18 | 2018-07-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-05-18 | 2018-07-11 | 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 | 2018-05-18 | 2018-07-11 | N |
| Respond appropriately to all alleged violations. | Health | 2018-05-18 | 2018-07-11 | 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 | 2018-05-18 | 2018-07-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-18 | 2018-07-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-18 | 2018-07-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-18 | 2018-07-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-05-18 | 2018-07-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-18 | 2018-07-11 | N |
| Provide activities to meet all resident's needs. | Health | 2018-05-18 | 2018-07-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-18 | 2018-07-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-05-18 | 2018-07-11 | N |
| 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. | Health | 2018-05-18 | 2018-07-11 | N |
| 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 | 2018-05-18 | 2018-07-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-05-18 | 2018-07-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-05-18 | 2018-07-11 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install | Health | 2018-05-18 | 2018-07-11 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-05-18 | 2018-07-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-05-18 | 2018-07-11 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-05-18 | 2018-07-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-05-18 | 2018-07-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-18 | 2018-07-11 | 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 | 2018-05-18 | 2018-07-11 | N |
| Provide or obtain dental services for each resident. | Health | 2018-05-18 | 2018-07-11 | N |
| 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. | Health | 2018-05-18 | 2018-07-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-05-18 | 2018-07-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-18 | 2018-07-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-05-18 | 2018-07-11 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Establish methods for sharing information. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-05-15 | 2018-06-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-05-15 | 2018-06-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-05-15 | 2018-06-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-15 | 2018-06-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-05 | 2018-04-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-01 | 2018-02-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-11-13 | 2017-11-14 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-04-04 | 2017-04-21 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-04-04 | 2017-04-21 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-04-04 | 2017-04-21 | N |
| Make sure that each residents' abilities in activities of daily living do not decline, unless unavoidable. | Health | 2017-04-04 | 2017-04-21 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-04-04 | 2017-04-21 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-04-04 | 2017-04-21 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-04-04 | 2017-04-21 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-04-04 | 2017-04-21 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-04-04 | 2017-04-21 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-04-04 | 2017-04-21 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-04 | 2017-04-21 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-04 | 2017-04-21 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-04-04 | 2017-04-21 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-04 | 2017-04-21 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-04-04 | 2017-04-21 | Y |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-09-13 | 2016-10-31 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-09-13 | 2016-10-31 | N |
| Restrictions on the use of flammable curtains. | Fire Safety | 2016-09-13 | 2016-10-31 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-08-19 | 2016-10-17 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-08-19 | 2016-10-17 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-08-19 | 2016-10-17 | Y |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2016-08-19 | 2016-10-17 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility | Health | 2016-08-19 | 2016-10-17 | Y |
| Provide care for each resident in a way that maintains or improves their quality of life. | Health | 2016-09-19 | 2016-10-17 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2016-09-19 | 2016-10-17 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2016-09-19 | 2016-10-17 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2016-09-19 | 2016-10-17 | N |
| Provide housekeeping and maintenance services. | Health | 2016-09-19 | 2016-10-17 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-09-19 | 2016-10-17 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-09-19 | 2016-10-17 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-09-19 | 2016-10-17 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-09-19 | 2016-10-17 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-09-19 | 2016-10-17 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2016-09-19 | 2016-10-17 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2016-09-19 | 2016-10-17 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-09-19 | 2016-10-17 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-09-19 | 2016-10-17 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-09-19 | 2016-10-17 | N |
| Provide or obtain dental services for each resident. | Health | 2016-09-19 | 2016-10-17 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-09-19 | 2016-10-17 | N |
| 1) Hire only people with 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. | Health | 2016-06-13 | 2016-06-28 | Y |
