Deficiency Records for Avamere Bellingham Health Care and Rehab Services
Updated as of August 01, 2021
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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2021-05-12 | 2021-06-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-22 | 2021-04-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-22 | 2021-04-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2020-11-19 | 2021-01-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-11-19 | 2021-01-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-11-19 | 2021-01-15 | Y |
| Provide appropriate foot care. | Health | 2020-11-19 | 2021-01-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-11-19 | 2021-01-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-10 | 2020-03-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-02-10 | 2020-03-05 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-02-10 | 2020-03-05 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-02-10 | 2020-03-05 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-02-10 | 2020-03-05 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2020-02-10 | 2020-03-05 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-02-10 | 2020-03-05 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-12-31 | 2020-01-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-05 | 2019-11-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-20 | 2019-07-18 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-05-20 | 2019-07-18 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-05-20 | 2019-07-18 | N |
| 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. | Health | 2019-05-20 | 2019-07-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-20 | 2019-07-18 | N |
| 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. | Health | 2019-05-20 | 2019-07-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-20 | 2019-07-18 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-05-20 | 2019-07-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-20 | 2019-07-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-20 | 2019-07-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-20 | 2019-07-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-20 | 2019-07-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-20 | 2019-07-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-20 | 2019-07-18 | 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 | 2019-05-20 | 2019-07-18 | 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 | 2019-05-20 | 2019-07-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-05-20 | 2019-07-18 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-05-20 | 2019-07-18 | 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 | 2019-05-20 | 2019-07-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-20 | 2019-07-18 | N |
| 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. | Health | 2019-05-20 | 2019-07-18 | N |
| Provide or obtain dental services for each resident. | Health | 2019-05-20 | 2019-07-18 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-05-20 | 2019-07-18 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2019-05-20 | 2019-07-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-20 | 2019-07-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-05-20 | 2019-07-18 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-05-20 | 2019-07-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-05-20 | 2019-07-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-20 | 2019-07-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-05-20 | 2019-07-18 | Y |
| 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. | Health | 2019-05-20 | 2019-07-18 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-20 | 2019-07-18 | Y |
| 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 | 2019-05-20 | 2019-07-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-20 | 2019-07-18 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-05-20 | 2019-07-18 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-05-20 | 2019-07-18 | Y |
| 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 | 2019-05-20 | 2019-07-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-20 | 2019-07-18 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-05-20 | 2019-07-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-05-20 | 2019-07-18 | Y |
| Implement a program that monitors antibiotic use. | Health | 2019-05-20 | 2019-07-18 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-05-08 | 2019-05-31 | N |
| 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. | Health | 2019-03-07 | 2019-04-10 | Y |
| 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 | 2019-03-07 | 2019-04-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-03-07 | 2019-04-10 | Y |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-03-07 | 2019-04-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-07 | 2019-04-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-03-07 | 2019-04-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-07 | 2019-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-07 | 2019-04-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-03-07 | 2019-04-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-03-07 | 2019-04-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-11 | 2019-04-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-02-11 | 2019-04-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-02-11 | 2019-04-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-12-19 | 2019-01-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-19 | 2019-01-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-31 | 2018-11-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-31 | 2018-11-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-10-03 | 2018-11-30 | Y |
| 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. | Health | 2018-10-03 | 2018-11-30 | Y |
| 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 | 2018-10-03 | 2018-11-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-03 | 2018-11-30 | Y |
| 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 |
| 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 | 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 enough food/fluids to maintain a resident's health. | 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 and maintain the bed rail. | 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 |
| 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 |
| 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 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 | 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 |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | 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 |
| 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 | 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 |
