A list of the most recent deficiencies for North Bend Post Acute. 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 properly protected cooking facilities. | Fire Safety | 2023-12-06 | 2024-02-14 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-12-12 | 2024-01-15 | 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 | 2023-12-12 | 2024-01-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-12 | 2024-01-15 | 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 | 2023-12-12 | 2024-01-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-12-12 | 2024-01-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-12 | 2024-01-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-12 | 2024-01-15 | 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 | 2023-12-12 | 2024-01-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-12 | 2024-01-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-12 | 2024-01-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-12 | 2024-01-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-12-12 | 2024-01-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-12 | 2024-01-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-12 | 2024-01-15 | 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 | 2023-12-12 | 2024-01-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-12 | 2024-01-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-12 | 2024-01-15 | N |
| 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. | Health | 2023-12-12 | 2024-01-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-12-12 | 2024-01-15 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-12-12 | 2024-01-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-12-12 | 2024-01-15 | N |
| Post nurse staffing information every day. | Health | 2023-12-12 | 2024-01-15 | 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 | 2023-12-12 | 2024-01-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-12 | 2024-01-15 | N |
| 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. | Health | 2023-12-12 | 2024-01-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-12-12 | 2024-01-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-12 | 2024-01-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-12 | 2024-01-15 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-12-12 | 2024-01-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-12 | 2024-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-12 | 2024-01-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-12 | 2024-01-15 | 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 | 2023-12-12 | 2024-01-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-12 | 2024-01-15 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Develop a communication plan. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Establish methods for sharing information. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-12-06 | 2024-01-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-04 | 2023-11-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-04 | 2023-11-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-04 | 2023-11-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-04 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-11-17 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-04 | 2023-11-17 | 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 | 2023-10-04 | 2023-11-17 | Y |
| 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. | Health | 2023-10-04 | 2023-11-17 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-10-04 | 2023-11-17 | Y |
| Post nurse staffing information every day. | Health | 2023-10-04 | 2023-11-17 | Y |
| 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 | 2023-10-04 | 2023-11-17 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-10-04 | 2023-11-17 | 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 | 2023-10-04 | 2023-11-17 | 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 | 2023-10-04 | 2023-11-17 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2023-10-04 | 2023-11-17 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-04 | 2023-11-17 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-10-04 | 2023-11-17 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-10-04 | 2023-11-17 | 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 | 2023-10-04 | 2023-11-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-28 | 2023-05-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-12 | 2022-10-10 | 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 | 2022-08-12 | 2022-10-10 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-12 | 2022-10-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-12 | 2022-10-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-12 | 2022-10-10 | 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 | 2022-08-12 | 2022-10-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-12 | 2022-10-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-12 | 2022-10-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-12 | 2022-10-10 | 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 | 2022-08-12 | 2022-10-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-12 | 2022-10-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-12 | 2022-10-10 | 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 | 2022-08-12 | 2022-10-10 | N |
| 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. | Health | 2022-08-12 | 2022-10-10 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-08-12 | 2022-10-10 | 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 | 2022-08-12 | 2022-10-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-12 | 2022-10-10 | 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 | 2022-08-12 | 2022-10-10 | N |
| Provide or obtain dental services for each resident. | Health | 2022-08-12 | 2022-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-12 | 2022-10-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-12 | 2022-10-10 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-08-12 | 2022-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-12 | 2022-10-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-08-12 | 2022-10-10 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-12 | 2022-10-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-12 | 2022-10-10 | N |
| 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. | Health | 2022-08-12 | 2022-10-10 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-12 | 2022-10-10 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-13 | 2022-02-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-06 | 2021-08-01 | Y |
| Protect a residents' right to refuse some types of non-requested transfers within the nursing home. | Health | 2019-10-16 | 2019-12-03 | 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 | 2019-10-16 | 2019-12-03 | N |
| 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 | 2019-10-16 | 2019-12-03 | 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 | 2019-10-16 | 2019-12-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-16 | 2019-12-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-10-16 | 2019-12-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-16 | 2019-12-03 | 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 | 2019-10-16 | 2019-12-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-16 | 2019-12-03 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-10-16 | 2019-12-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-16 | 2019-12-03 | 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 | 2019-10-16 | 2019-12-03 | 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 | 2019-10-16 | 2019-12-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-10-16 | 2019-12-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-16 | 2019-12-03 | 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 | 2019-10-16 | 2019-12-03 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-10-16 | 2019-12-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-16 | 2019-12-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-16 | 2019-12-03 | 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 | 2019-10-16 | 2019-12-03 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-10-16 | 2019-12-03 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-16 | 2019-12-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-16 | 2019-12-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-16 | 2019-12-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-16 | 2019-12-03 | 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 | 2019-10-16 | 2019-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-16 | 2019-12-03 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-09 | 2019-11-07 | N |
